Sustaining medical home transformation is equally as important as the transformation process itself.​​​


​Something that is “sustainable” is defined as being able to continue for a long time without depleting all available resources. In a pediatric practice this can include:

  • ​​Financial resources (eg, being able to continue medical home activities after funding for the transformation process ends; securing new financial resources)
  • Human resources (eg, avoiding staff and/or clinician burn out; making sure that one person is not doing all the work; orienting new staff to the medical home)
  • Material resources (eg, continuous distribution of educational materials and information to patients and families)

Lee Partridge | National Partnership for Women and Families

 Fundamental Principles of Medical Home Sustainability

  • ​​Creation of a well-developed, clear vision for medical home transformation, implementation, and sustainability. Communication about this vision to the entire practice team
  • Presence of written, formal processes and protocols related to specific medical home activities enacted before or during the transformation process
  • Clear and regular communication of processes and protocols to all staff, clinicians, families/caregivers, and patients
  • Clear and regular communication about the practice’s progress towards transforming into a medical home to all staff, clinicians, families/caregivers, and patients
  • Ongoing collection and analysis of data related to a practice’s transformation processes. This data can be used to justify sustaining a patient-centered medical home
  • Active workforce buy-in and engagement in the patient-centered medical home concept
  • Adequate payment for activities conducted and services offered through a patient-centered medical home
  • Continuous investigation of current events and policies specific to medical home implementation which could improve health care delivery as well as patient, and clinician experiences​

 Tools and Resources

APEX Digital Navigator
Provides examples of policies and procedures implemented by pediatric practices undergoing the medical home transformation process.

Selling Quality to Management: How to Get Management Buy-In to New Quality Initiatives
Provides strategies to encourage engagement and buy-in from executive and managerial staff.

Strategies for Achieving Whole-Practice Engagement and Buy-in to the Patient-Centered Medical Home
Includes strategies for obtaining organizational buy-in and whole-staff engagement.

Tips for Sustaining the Success of a Quality Improvement Project
Provides four tips for pediatric practices to assist with sustainability of quality improvement projects, such as medical home implementation.

Medical Home Coding Fact Sheet
Includes a collection of Current Procedural Terminology Codes for medical home practices.

Bright Futures and Preventive Coding Fact Sheet
Provides a comprehensive listing of preventive medicine service codes frequently used in pediatric medical homes.

EQIPP: Medical Home
The American Academy of Pediatrics offers an EQIPP course, Medical Home, which guides users through the detailed quality improvement process necessary to undergo the pediatric medical home transformation.​