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This page includes a collection of tools and resources for pediatric practices interested in learning more about the pediatric medical home.Updated: May 2020 Getting Started The following resources support pediatric clinicians and practice teams in pediatric medical home implementation:Building Your Medical Home: An Introduction to Pediatric Primary Care TransformationCreated by the former National Center for Medical Home Implementation, this online resource guide provides direction, resources, and tools to pediatric medical home clinicians and practices seeking to advance their knowledge and understanding of the medical home concept as it relates to practice transformation.Medical Homes @ Work e-NewsletterThis monthly publication from the National Resource Center for Patient/Family-Centered Medical Home provides the most up to date tools, resources, literature, and educational opportunities for state Maternal and Child Health Title V / Children and Youth with Special Needs Programs, family/caregivers, pedaitric clinicians, and others with medical home implementation. American Academy of Pediatrics Policy Statement: The Medical HomeThis policy statement from the American Academy of Pediatrics provides adefinition and framework for the pediatric medical home and its core components. Fostering Partnership and Teamwork in the Pediatric Medical Home: A "How-To" Video SeriesThis 3-part video series provides step-by-step instructions on increasing family-centered care and team work.Creating Efficiency: Team HuddlesBuilding a Stronger Pediatric Medical Home: Family Advisory GroupsEnhancing Collaboration with Families: Care Partnership Support Family-Centered Care Provision of family-centered care is a key function of a pediatric medical home. At its core, the pediatric medical home acknowledges and respects that families are the primary caregivers, experts, and supports for their child. Family-centered care honors the strengths, cultures, traditions, and expertise that family members bring to the medical home team and fosters a respectful partnership between families and clinicians. The following are resources for child health professionals interested in implementing and enhancing family-centered care:Enhancing Family Engagement through Quality Improvement Fact SheetBuilding Your Medical Home: Implementing Family-Centered CarePositioning the Family and Patient at the Center: A Guide to Family and Patient Partnerships in the Medical Home Family-Centered Care Assessment Tool for FamiliesFamily-Centered Care Assessment Tool for ProvidersMedical Home Family Index and Survey: EnglishChineseSpanishBenchmark DataFrequently Asked QuestionsCreating a Patient and Family Advisory Council: A Toolkit for Pediatric PracticesFamily Engagement Guide: The Role of Family Health Partners in Quality Improvement Within a Pediatric Medical HomeParent Partners: Creative Forces on Medical Home Improvement TeamsExtra-Ordinary Care: Improving Your Medical Home, A Learning Guide for Families and CaregiversPatient-Clinician Communication: Basic Principles and ExpectationsPowerful Partnerships: A Handbook for Families and Providers Working Together to Improve Care The Pediatrician's Role in Family Support and Family Support ProgramsTitle V Toolbox for Family Participation Compendium: Tools for Engaging Patients in Your PracticeParent Advisory Groups in Pediatric Practices: Parents' and Professionals' Perceptions Fostering Partnership and Teamwork in the Pediatric Medical Home: A "How-To" Video SeriesFamily Engagement Self-Assessment Tool Care Coordination Care coordination involves the "deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services." The following is a list of resources for child health professionals and others interested in implementing and enhancing care coordination: Building Your Medical Home: Coordinated Care Patient- and Family- Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems Beyond the Medical Home: Coordinating Care for Children Pediatric Care Coordination: Beyond Policy, Practice, and Implementation, a Webinar Series Pediatric Care Coordination Curriculum Care Coordination Measurement Tool Sample Care Coordinator Job Descriptions: Care Coordinator Job Description Parent Consultant Job Description Special Needs Consultation and Care Coordination Program Job Description Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework Implementing a Care Coordination Program for Children with Special Healthcare Needs: Partnering with Families and Providers Primary Care Referral and Feedback Form Transitions For more information about care coordination, including the National Center for Care Coordination Technical Assistance, visit the care coordination Web page. Care Planning A care plan, or a medical summary, assists with the implementation of successful care coordination within a pediatric medical home. A comprehensive care plan includes all historical, medical, and social aspect of a child and family's needs. It also includes the following:Key interventionsRoles and responsibilities of each care team memberContact information In a pediatric medical home, a care plan should be created in partnership with the family and youth. The following is a list of resources that can be used when creating and implementing a shared plan of care within a pediatric medical home:Achieving a Shared Plan of Care with Children and Youth with Special Health Care NeedsBuilding Your Medical Home: Sample Pediatric Care PlanCare Planning Process and Resources Culturally Competent Care A family’s cultural background—including beliefs, rituals, and customs—are recognized, valued, and respected within a pediatric medical home. All efforts are made to ensure that the child or youth and family understand the details of the medical encounter and the care plan. The following resources are available to help with implementation and enhancement of culturally competent care: Language Access in Pediatric Primary CareStrategies to Enhance Access to Pediatric Medical Homes for Hispanic Communities Culturally Effective Care Toolkit Health Equity Resources for Pediatric Clinicians Providing Care for Immigrant, Migrant, and Border Children Signage for Multilingual Healthcare Settings Culture, Language and Health Literacy: Resources for Clinicians to Improve Cultural Competency Think Cultural Health: Cultural and Linguistic Competency Resources More than Words Toolkit Series: Improving the Quality of Translated Patient Materials Multicultural Health Care: A Quality Improvement Guide Clearview 360: Cultural Competency Organizational Self-Assessment Tool A Comprehensive Framework and Preferred Practices for Measuring and Reporting Cultural Competency National Center for Cultural Competency, Georgetown University Team-based Care Team-based care improves communication and health care for patients and families. The following resources are available to help with the implementation of team-based care:Fostering Partnership and Teamwork in the Pediatric Medical Home: A "How-To" Video SeriesBuilding Your Medical Home: Form a Medical Home Improvement TeamCreating Efficiency: Team HuddlesTeam-based Care in Pediatric Medical HomesCore Principles and Values of Effective Team-Based Health CareKey Elements of Highly Effective TeamsPrimary Care Team GuideCambridge Health Alliance Model of Team-based Care Implementation Guide and Toolkit Transition to Adult Care Health care transition is the process of moving from a child to an adult model of care with or without transfer to a new clinician. For pediatric practices, this includes the following: creating a transition policy for the practiceidentifying transition-aged youthleading routine transition readiness/self-care skill assessmentsincluding transition needs into a plan of carepreparing a medical summaryhelping to identify adult providerspreparing a transfer packageensuring the transfer is completedPediatricians can use the following resources to support youth transitioning from pediatric to adult care:Clinical Report: Supporting the Health Care Transition from Adolescence to Adulthood in the Medical HomeSix Core Elements of Health Care Transition 2.0: Transitioning Youth to an Adult Health Care ProviderPediatric to Adult Care Transitions Initiative: Customized Tools for Diseases and ConditionsIncorporating Pediatric-to-Adult Transition into National Committee for Quality Assurance Patient-Centered Medical Home RecognitionStarting a Transitions Improvement Process Using the Six Core Elements of Health Care Transition2017 Coding and Reimbursement Tip Sheet for Transition from Pediatric to Adult Health CareFree Continuing Medical Education Podcast: Transitioning Pediatric Patients to Adult Health CareFree Continuing Medical Education Video Series: Health Care Transition for Adolescents and Young AdultsFor more information about transitions of care, including Got Transition, the Center for Health Care Transition Improvement, visit www.gottransition.org. Measuring and Paying for Your Medical Home Practices that provide care consistent with a medical home approach are well positioned to advocate and negotiate for improved and appropriate payment. The following resources focus on payment for medical home activities within a practice: Building Your Medical Home: Sustain Your Medical Home Measuring Medical Homes: Tools to Evaluate the Pediatric Patient- and Family- Centered Medical Home Medical Home Index: Full Version: English Full Version: Spanish Short Version Benchmark Data Frequently Asked Questions Coding for Care Management and Other Non-Direct Services Medical Home Coding Fact Sheet Coding for Pediatric Preventive Care The Medical Home for Children: Financing Principles Principles of Child Health Financing Online Implementation Guides for Pediatric Practices and Professionals Many organizations have created online resource guides, toolkits, and training opportunities for clinicians and practices implementing medical home. The following is a collection of these resources: Building Your Medical Home: An Introduction to Pediatric Primary Care TransformationMedical Home Modules for Pediatric Residency ProgramsTransforMED: Transforming Medical PracticesAmerican College of Physicians Practice Advisor Patient-Centered Medical Home Resource Center, Agency for Healthcare Research and Quality