This group pediatric practice provides family-centered care for children with special health care needs in a low-income, rural community. Patients and families benefit from a full time case manager that assists with coordinating care and following up with specialty providers.

Implementation Insights:

  • Co-locate multidisciplinary services including mental and behavioral health with primary care.
  • Establish a 24 hour telephone service to enhance access to care.
  • Foster relationships with specialty care centers in the community to enhance care coordination.

    Updated: June 2016

 Background Information

  • Type of Practice: Group pediatric practice
  • Location: Elkin, North Carolina
  • Population Served: Over 3,000 children and families have been served through this practice; 85% of patients are Medicaid beneficiaries.

 Pediatric Medical Home Implementation Strategies

  • Expand clinic hours to accomodate evening appointments throughout the week.
  • Expand access to care by staffing a full time Registered Nurse to answer family concerns via telephone; provide 24 hour access to a physician (via telephone) in case of an emergency.
  • Co-locate multiple services within the clinic to enhance continuity of care, including the following:
      • Behavioral and mental health services
      • Occupational therapy
      • Speech therapy
  • Offer classes to families on topics of interest including parenting and nutrition.
  • Hire a full time case manager to assist with making specialist appointments, following up on missed appointments, and answering any questions families may have about appointments with specialists.
  • Provide patient education materials and evaluation forms in English and Spanish.
  • Provide Reach Out and Read books in multiple languages.
  • Convene weekly team meetings, invite community partners such as legal aid, public health, and nutrition programs to attend these meetings
  • Maintain close relationships with specialists at tertiary care centers for real time access to patient information.


  • Despite impressive results including numerous indicators of cost savings for Medicaid beneficiaries, the practice continues to struggle with fiscal sustainability. Leadership recently started a non-profit organization to help raise funds for co-located services within the practices, including further classroom space, an accessible playground and physical therapy.

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