This program connects children and youth in foster care to a pediatric medical home by creating structured partnerships between local Departments of Social Services, primary care providers, and a multidisciplinary network of pediatric health professionals.

Implementation Insights:

  • Create formal written agreements between organizations that care for children and youth.
  • Create standardized documentation that can be used by multiple health professionals.
  • Provide a variety of technical assistance and educational offerings to support local implementation of the foster care medical home model.

    Updated: March 2016

 Background Information

  • Type of Practice: State Chapter of the American Academy of Pediatrics
  • Location: The project is implemented locally through the state's 100 counties.
  • Population Served: Approximately 10,000 infants, children, and youth in foster care. One third of the population served are children ages 0-5 years.

 Pediatric Medical Home Implementation Strategies

  • Create a multidisciplinary advisory council that represents diverse partners and stakeholders.
  • Partner with numerous community and state organizations, including the following:
      • State Medicaid Agency
      • State Chapter of the American Academy of Family Physicians
      • State Division of Social Services
      • State associations representing social services and mental health professionals
      • County Departments of Social Services
  • Build continuous relationships between three systems that care for children and youth in foster care, including the following:
      • Local Department of Social Services
      • Primary care practices (medical homes)
      • A multidisciplinary network of professionals who care for children and youth in foster care (referred to as the medical home network and includes behavioral health clinicians, care managers, pharmacists, and psychiatrists, among others)
  • Create a formal Letter of Agreement between the local Department of Social Services, medical home, and medical home network. The letter should outline roles and responsibilities of each organization as they pertain to caring for children and youth in foster care.
  • Establish formal care coordination agreements between local Departments of Social Services, primary care practices, and pediatric health professionals.
      • Establish agreements that allow local Departments of Social Services to access a web-based Medicaid claims database to enhance care for children in the foster care system.
      • Utilize standard health summary and health history forms that can be shared between multidisciplinary providers and local Departments of Social Services.
      • Assign children and youth in foster care to specific primary care practices; encourage continuity of care at assigned practices if foster care placements change.
  • Provide technical assistance, support, and training to the aforementioned organizations and individuals, including the following opportunities:
      • Continuing Medical Education (CME) events
      • Webinars
      • Web-based instructional and testimonial videos by key stakeholders, which explain and promote the medical home model for the foster care population
      • Web-based repository of tools and resources
      • Online training courses/modules


  • The project assigns children and youth in the foster care system to one specific primary care practice to enhance continuity of care. This is often challenging, particularly when foster care placements change.
      • To overcome this challenge, the project works to provide education, enhance understanding, and promote value of the medical home model.
      • The project also develops and disseminates tools that promote care coordination for children and youth in the foster care system, including protocol for how to access care when children are placed in different counties.
  • The state has a county administered social services system which implement the project locally. This creates a level of complexity due to vastly different county-level capacity and culture.
      • To overcome this challenge, the project utilized standardized health history and health summary forms and provided training to social service employees in the utilization of these forms. Self paced, on demand, web-based courses are available to all social services staff.
  • The siloed nature of the health care system presents a challenge in ensuring accessible behavioral health services for children and youth in foster care.
    • Project leadership and staff participated in a taskforce charged with creating a streamlined "out of network" agreement for children in foster care, and recommended protocols for provision of behavioral heath services for children in foster care.

 Additional Information

  • For additional information, contact Elizabeth Hudgins, Executive Director of the North Carolina Pediatric Society:
  • Visit the Fostering Health North Carolina Web site for additional information about the project, including a collection of tools and resources used to train project staff on topics related to care coordination and pediatric medical home implementation.