Texas Children's Health Plan is a Medicaid managed care organization that collaborated with the Baylor College of Medicine to open the Centers for Children and Women, clinics that serve as a patient- and family-centered medical home. The project's family-centered, multi-disciplinary approach to care has resulted in a reduction in Emergency Department visits, significant cost savings, and high family satisfaction ratings.
​Implementation Insights:
  • Implement quality improvement methodology to facilitate implementation of the medical home model of care.
  • Co-locate behavioral health, dental health, and primary care services.
  • Train all staff in motivational interviewing to encourage a family-centered approach to care.

    Updated: July 2016

 Background Information

  • Type of Practice: Capitated Clinic in a Health Plan
  • Location: Houston, TX
  • Population Served: Since inception in 2013, the clinic has served over 14,000 Medicaid beneficiaries.

 Pediatric Medical Home Implementation Strategies

  • Utilize quality improvement methodolgy to implement tests of change in clinic.
  • Engage families in quality improvement activities to ensure the family perspective is integrated into changes tested throughout the clinic.
  • Distribute family satisfaction surveys monthly; analyze survey results and test changes in practice based on feedback obtained from families.
  • Expand clinic hours to enhance access to care.
  • Co-locate behavioral/mental health and dental services with primary care.
  • Convene a multidisciplinary health care team to provide comprehensive care to patients and families. The team may include the following members:
      • Pediatricians
      • Nursing staff
      • Pharmacists
      • Dietitians
      • Health educators
      • Social workers
      • Psychologists
      • Psychiatrists
      • Patients and families
  • Continuously promote implementation of team-based care through the following strategies:
      • Facilitate daily team huddles
      • Organize debriefs throughout the day to discuss specific issues and challenges
      • Train all staff in TeamSTEPPS
  • Integrate a care coordinator (Registered Nurse) into the clinical practice to conduct the following activities:
          • Lead daily huddles
          • Maintain population health registries
          • Coordinate between primary care and behavioral health services for patients and families
          • Conduct outreach to families between appointments
          • Collaborate with pharmacy staff to enhance medication adherence
  • Facilitate annual cultural competency training for all staff.
  • Develop care plans in collaboration with pediatricians, subspecialists, and families.
  • Train all staff in motivational interviewing strategies to ensure engagement of families in the creation of care plans and other clinic activities.
  • Implement an evaluation strategy to determine the effectiveness of specific interventions/changes. Evaluation components of the project may include the following:
      • Tracking Body Mass Index for patients who participate in motivational interviewing with clinicians.
      • Utilize the Healthcare Effectiveness Data and Information Set (HEDIS) metrics on Attention-Deficit/Hyperactivity Disorder (ADHD) medication initiation to track effectiveness of behavioral health integration.


      • Opening a clinic that functions as a medical home involved significant training and culture change among staff, resulting in high rates of staff turnover.
      • To overcome this challenge the project facilitated multiple staff trainings on components of the medical home model such as team-based care, cultural competence, and motivational interviewing.

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