Edgardo Hiladolgo, MD

Guam

Medical Home for CSHCN in Guam

Purpose: Bring together resources and information to overcome barriers to medical homes in the community. 

Activities: 1) Establish a working task force; 2) clarify insurance policies relevant to CSHCN; 3) identify training needs for community pediatricians; and 4) consult with Hawaii medical home leaders to develop training program suitable for pediatricians in the community.

Outcome: N/A

David Hirsch, MD

Phoenix, AZ

Improvising Transition to Adult Care for CSHCN

Purpose: Assess needs of YSHCN and families with respect to transitions to adulthood.

Activities: 1) Develop and evaluate strategies which may increase adolescent compliance and participation in medical homes; and 2) identify a potential statewide network of adult service providers to transition youth to for adult health care needs.

Outcomes: N/A

Matthew Masiello, MD

Johnstown, PA

Clinic for CSHCN

Purpose: Use task force groups of 125 regional health care professionals to coordinate services for CSHCN. 

Activities: 1) Enhance communication and coordination of services between clinic, local health care agencies, and tertiary care centers through implementation of Every Child Deserves a Medical Home curriculum.

Outcome: The groups conducted a needs assessment of parents of CSHCN to help provide a more local coordinated resource/referral environment, and enhance communication between clinic, local health care agencies, and tertiary care centers. With the needs assessment complete, additional funding will be sought to formally develop: a special needs clinic, a database to better track these families and a resource manual for families.

Donald Burgess, MD

Kennebunk, ME

Developmental Resource Program

Purpose: Assess the level of effectiveness of present resources to develop: 1) a more coordinated and integrated mental health program, and 2) a more effective system of communication between providers with an emphasis on providing children with a medical home.

Activities: 1) Develop a diverse community collaborative to research and inventory existing mental health resources; 2) explore various ways of increasing communication and collaboration between resources and providers and 3) discuss various models of maintenance and follow-up for children with mental health needs.

Outcome: A plan was established to: 1) develop a needs assessment survey of parents and providers of children with mental health and developmental needs; and 2) organize a central resource center in New York County for dissemination of information and resources to parents and providers in the area.

Quentin Humberd, MD

Cunningham, TN

Medical Home Training Program

Purpose: Establish an interdisciplinary steering committee to address barriers to care facing CSHCN in Tennessee and increase collaboration among stakeholders.

Activities: One or more core training teams will be recruited to: 1) attend the AAP Every Child Deserves a Medical Home Training Program and lead implementation of a collaborative training program in Tennessee; 2) conduct community educational forums geared to parents, pediatricians, and other health professionals.

Outcome: The project allowed: the recruitment and training of two core training teams; the successful planning and implementation of four community forums; and the plans for garnering resources to fund a sustainable Medical Home Training Program.

Tools Developed: 1) A project fact sheet (using the AAP What is a Medical Home fact sheet); 2) an open-ended survey: Tell Us What You Think; (the adapted versions of the Medical Home Surveys for families, physicians and other providers); and 3) a flyer template used to announce and promote the community forums.