This community pediatric practice is participating in the "Early Access to Care AZ" initiative. This initiative convenes regional multidisciplinary teams of child health professionals led by a pediatrician. Teams work together to conduct early screening, diagnosis, and treatment of children and youth with Autism Spectrum Disorder (ASD) in the context of the medical home model of care. Although this practice worked specifically with children and youth with ASD, the team's pediatric medical home implementation strategies can be utilized by clinicians and practices caring for children and youth with a variety of special health care needs.
Implementation Insights:
  • Form a multidisciplinary and cross-agency team of professionals who care for children and youth with special health care needs.
  • Facilitate team trainings on medical home implementation, screening, and follow-up for children and youth with special health care needs.
  • Organize teleconference appointments with specialists for patients and families.

Updated: October 2021

 Background Information

  • Type of Practice: Solo Pediatric Practice
  • Location: Prescott Valley, Arizona
  • Population Served: Children at risk for or diagnosed with Autism Spectrum Disorder.

 Pediatric Medical Home Implementation Strategies

  • Form a regional multidisciplinary team of child health professionals, including a community pediatrician (team leader), an early intervention specialist, and a school social worker, who will work together to screen, diagnose, and treat children with Autism Spectrum Disorder (ASD).
  • Over a period of 6 months, participate in a training focused on educating community pediatricians to screen, diagnose, and treat children who are at risk for or diagnosed with ASD. The training consists of the following:
      • Online learning modules
      • Independent reading assignments
      • Webinars
      • Online case study discussions
      • Two in-person meetings
  • Participate in team trainings (with the lead pediatrician, early intervention specialist, and school social worker) focused on the following:
      • Training on how to use the Autism Diagnostic Observation Schedule (ADOS)
      • Development of a protocol for recognizing and referring children at risk for ASD for follow-up services
  • Participate in medical home implementation trainings to ensure care is provided within the medical home model.
  • Develop and implement regional resources, trainings, support groups, and other educational offerings to families of children diagnosed with ASD.
  • Enhance accessibility to specialty care within the medical home model by offering telemedicine consultations to families with specialists in the following areas:
      • Developmental pediatrics
      • Psychiatry
      • Gastroenterology
      • Neurology
      • Sleep medicine
      • Genetics
      • Psychology
  • Employ bilingual and bicultural staff.
  • Recruit a parent/caregiver volunteer to provide peer support and guidance to families who have children diagnosed with ASD.


  • The practice is located in a small rural community, which creates challenges in ensuring adequate services (such as Applied Behavior Analysis therapy) are available to families and patients. The practice builds strong relationships with specialty care clinicians and organizes teleconferences between specialists, patients, and families to enhance accessibility to services that may not be readily available directly in the community.

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