Statewide Medical Home Development Grants
The Statewide Medical Home Development Grants 93.110F are to promote access to ongoing comprehensive care through a medical home for all children with special health care needs (CSHCN). The grants will assist in the development and implementation of a statewide strategy for medical home implementation for children with special health care needs. These strategies include:

1. Working with primary care providers to implement the medical home concept
2. Incorporating well-defined strategies for coordination of primary care with specialty/subspecialty care and
3. Demonstrating care coordination models that link the medical home to the community-based system of services.

These activities will serve as examples within the State and nationally to stimulate the operation of the medical home concept. Activities will coordinate with the Title V needs assessment activities related to medical home, and project outcomes, reporting, and evaluation will be incorporated into ongoing activities of the State Title V Block Grant.

Integrated Services Grants (7/1/01 - 7/1/05) Adobe PDF

• Utah Abstract
• Washington Abstract

MCHB Medical Home Grantees (3/31/02– 3/30/05) Adobe PDF

• Arizona Grant Abstract
• Arkansas Grant Abstract
• Hawaii Grant Abstract
• Iowa Grant Abstract
• Minnesota Grant Abstract
• New York Grant Abstract
• South Carolina Grant Abstract
• Vermont Grant Abstract

MCHB Medical Home Grantees (3/31/01 – 3/30/04)

La Vida Sana Medical Home Initiative
Email: jaceves@salud.unm.edu | Grant Abstract

The overall goal is to make the Medical Home Initiative operational in 10 New Mexico clinic sites so that the seven essential elements are fully functional for all CSHCN and their families at these sites. STRATEGY 1: To increase knowledge about the seven components of medical home in 10 identified clinic sites around the state. STRATEGY 2: To facilitate assessment of and incorporation into practice of improvements in the seven components of medical home in identified clinic sites around the state. STRATEGY 3: To increase collaboration between primary care clinic sites who care for CSHCN and other community services that enhance their care. STRATEGY 4: To increase collaboration between primary care clinic sites who care for CSHCN and other community services that enhance their care.

The Massachusetts Medical Home Project (MMHP)
The MMHP will enhance efforts already underway to improve services for Massachusetts children with special health care needs and their families. DSHN has already initiated an incremental plan to shift the locus of case management out of DPH regional offices and into pediatric practices; eventually, DPH case managers will provide care coordination in practices statewide. Grant funds will permit us to go further, however, to create a system linking primary care to public health and other service systems. Funds will be used for outreach, training, and TA to providers to promote family-centered care. They will be used to develop materials for parents and providers concerning “medical home” and a partnership approach to care, and to promote participation in parent-to-parent support activities. Funding will also support two efforts aimed at maximizing long-term impact of MMHP: the completion of a rigorous evaluation of Medical Home-based care coordination, and the development of a framework for an integrated Medical Home-public health data management system.

Home Owner’s Insurance: Strengthening the Foundation of the Medical Home
E-Mail: jepsenc@oregon.uoregon.ed

The purpose of the Home Owner’s Insurance: Strengthening the Foundation of the Medical Home is to promote the provision of comprehensive services to CSHN through a Medical Home by building partnerships among community professionals and parents and facilitating changes in the management of CSHN in primary care offices throughout Oregon.

The Pennsylvania Medical Home Initiative (MHI)
E-mail: mgatto@paaap.org | Grant Abstract

The purpose of MHI is to improve the quality of life for children with special health care needs (CSHCN) and their families by building sustainable medical home (MH) teams in primary care practices throughout PA. The MHI will establish a statewide infrastructure to provide practical, team and community-based MH education and quality improvement programs using an established format, Educating Physicians In their Communities (EPIC). Through its advocacy efforts MHI will disseminate the MH principles to policy makers, state agencies and third party payers to assure statewide recognition of the MH and improve reimbursement for MH services.

The Rural Medical Home Expansion Project (RMHEP)
E-mail: jeanne.w.mcallister@hitchcock.org | Grant Abstract

The RMHEP supports statewide development of community-based medical homes for Children with Special Health Care Needs (CSHCNs) by surveying and informing pediatric practices in VT and NH about the medical home concept and providing them access to a continuous improvement process involving partnerships with parents, linkages to community resources, and new Medicaid reimbursement.

Utah Collaborative Medical Home Project
E-mail: ccarter@doh.state.ut.us | ftait@doh.state.ut.us | Grant Abstract

The purpose of this Project is to develop and implement a statewide system to support medical homes for children with special health care needs (CSHCN) in primary care settings. The major components of the Project include:

1. Development of a web-based Medical Home resource to facilitate access to information about the Medical Home and family-centered care, medical literature on chronic conditions, practice guidelines, and information and links for a broad range of resources.
2. Phase 1 implementation will establish a Medical Home Facilitator (Facilitator) and Family Advocates in four disparate pediatric offices across the state to integrate family-centered care and Medical Home services into the practices. Project Directors, staff, and the Family Advocate Coordinator will work closely with the practice-based personnel during training and to provide ongoing support.
3. With Medicaid as a partner, we will identify and implement existing mechanisms for reimbursing medical home services. We will develop strategies for long-term sustainability and funding of primary care medical homes with Medicaid, other third party payers, and provider organizations.

The Medical Home Leadership Network: Washington State families and professionals working together to promote medical homes statewide
Email: orville@u.washington.edu | Grant Abstract

The purpose of the Project is to implement and evaluate a coordinated, sustainable, statewide network of families and professionals to promote the availability and accessibility of medical homes for children with special health care needs (CSHCN) and their families in Washington State. We will do this by building on the existing infrastructure of the Medical Home Leadership Network (MHLN), our statewide system begun in 1994-95 as a SPRANS grant to promote and support medical homes. The MHLN is a regionally based statewide network of 15 experienced, volunteer medical home teams -- typically composed of a pediatrician, a public health nurse, an early intervention family resources coordinator, and a parent -- who provide technical assistance and support to their colleagues around medical homes. Approximately 18% of the children in Washington State are children with special health care needs. The Washington State Dept. of Health estimates that fewer than 47% of these children receive services in the context of a medical home. The MHLN will collaborate with the Washington State Title V Children with Special Health Care Needs Program, Medicaid, the Infant Toddler Early Intervention Program (IDEA, Part C), other state agencies, the Washington Chapter of the American Academy of Pediatrics, the national American Academy of Pediatrics Medical Home Program, family organizations, the regional medical home teams, Molina Healthcare plan and other partners to address the barriers to medical homes in Washington at both the health care system and individual level.

• Project Director: Kathryn Smith, RN, MN
  Location: Public Health Foundation Enterprises, Inc/City of Industry, CA
• The purpose of the project is to improve the coordination of care for CSHCN and their families by establishing an integrated training program for pediatricians and their staff, quality assurers and parents in their respective roles in the delivery of services within medical homes. This project will provide joint training opportunities and new partnerships by expanding medical home service delivery to CSHCN.
• Project Update: The Medical Home Project Training Curriculum, which consists of 8 modules is complete and has been shared with several potential training sites. Project staff has provided training to a variety of sites including the local American Academy of Pediatrics (Chapter 2), Los Angeles County Department of Children and Family Services, and Children's Hospital Los Angeles Craniofacial and Cleft Center. Realizing that providing a medical home requires additional time and resources, a reimbursement task force has been assembled to explore these issues.

The Caring Community for Children in Foster Care Project

• Project Director: Cheryl Takemoto
  Location: Parent Educational Advocacy Training Center (PEATC)/Fairfax, VA
• The primary purpose of this project is to improve the health care outcomes for culturally diverse children in foster care who have special health care needs, by creating a collaborative, coordinated, family-centered system of health care.
• Project Update: PEATC continues its efforts toward educating the many individuals involved in caring for CSHCN in foster care. A training video is presently in development focusing on access to care for children in foster care. Also in development are guides for foster parents, social workers, and pediatricians. A "Foster Parent Mentoring Program" has been initiated which utilizes the skills and knowledge of experienced foster parents to provide one-to-one support to new foster parents. Another exciting endeavor has been the development of "health passports" for children serviced by social services in Fairfax County. This method of tracking health records for foster children is scheduled to pilot in Spring 2000.

• Project Director: Donna Gore Olsen
  Location: The Indiana Parent Information Network/Indianapolis, IN
• This project will target CSHCN who reside in the inner city area surrounding the North Arlington Health Center. By means of a team consisting of a pediatrician, a social worker, and two Parent Liaisons, this project will develop a medical home model to
  1. Collaborate with community partners to identify CSHCN that do not have a medical home
  2. Connect the targeted children with medical homes
  3. Identify barriers to accessible care and provide training to health care professional in the targeted community; and
  4. Coordinate public and private services and resources that are needed by the child and family through linkages and partnerships with health care professionals
• Project Update: The Indiana Medical Home Project is working to identify families of CSHCN and offer them a medical home. The project is also placing a great deal of effort toward training community agencies and health care providers on the medical home concept. Educational materials aimed toward medical students and residents are in development. The project team is investigating opportunities to include education of medical homes into Indiana University School Health/Social Pediatrics curriculum.

• Project Director: Calvin Sia, MD
  Location: Hawaii Medical Association/Honolulu, HI
• Malamo Pono will promote accessible community-based, family-centered, culturally competent medical homes which provide comprehensive coordinated services for CSHCN. Three diverse communities will assure and evaluate medical homes for CSHCN. Strategies demonstrated and evaluated in these communities will be replaceable elsewhere.
• Project Update: The Malama Pono project is using technology to provide CSHCN with a medical home. Three web sites are currently in development which will be used to disseminate current information on local resources for families, allow for communication and coordination of services through email, and assist caregivers and families in the development of an Individual Family Support Plan (IFSP) on-line. Work toward a telemedicine project has begun which will assist in providing a medical home to premature and low-birth-weight infants by enhancing the communication and coordination of services through technological communication links to at least two Malama Pono island sites.

• Project Director: Vidya Bhushan Gupta, MD, MPH
  Location: Metropolitan Hospital Center/New York, New York
• The goal of this project is to provide a medical home for CSHCN so that they receive preventative and therapeutic medical care in a culturally competent manner. Partnerships will be developed with community agencies serving CSHCN, such as neighborhood health clinics, home health care agencies, community-based mental health clinics, early intervention programs, and New York City Board of Education so that children receive the necessary continuum of medical, developmental, and support services in the community. The families of CSHCN will be empowered to openly communicate and participate in the decision making process so that they are able to utilize the resources in the community more efficiently to meet their medical and psychosocial needs.
• Project Update: Dr Gupta and his staff have started a weekly "Children with Special Health Care Needs" interdisciplinary clinic which provides comprehensive services for the entire family. The clinic staff consists of a pediatrician, care coordinator, educator or developmental pediatrician, social worker, and psychiatrist as needed. A developmental play group has been initiated for children ages 0-3 years. The play group is directed by an early childhood educator who provides transitional services for children awaiting early intervention services and for at-risk children who do not qualify for early intervention. Parent group meetings are offered every two weeks to provide parents with educational opportunities and to give parents the opportunity to meet with and support other parents of children with special needs.

• Project Director: Kathy Allely
  Location: Stone Soup Group (SSG)/Anchorage, AK
• This project supports care coordination and linkage between subspecialists, the medical home, early intervention services, and other community based supports through the SSG Parent Navigation project. Using a family centered and collaborative model, SSG is developing a protocol for medical home care coordination which can be used by medical and service providers. A care coordination guide including a visual guide to the system is being developed and distributed. SSG Parent Navigators will be a conduit between the subspecialty clinics, primary doctor and system of services.
• Project Update: Stone Soup Group continues to offer Parent Navigation services to families. Parent Navigators are parents of CSHCN who have experience coordinating care. They provide care coordination services by focusing on integrating the child's medical care with community services and supports. Another activity is the development of a "navigation tool" that will describe health, developmental, financial, and community resources for CSHCN and their families.

• Project Director: Karen Burstein, PhD
  Location: Phoenix Pediatrics/Phoenix, AZ
• The purpose of this project is to improve the quality of pediatric health care on two distinct levels:
  1. On a system-wide level, by systematically identifying the indicators of effective practices within the medical home and improving the interface between primary and specialty care within the managed care framework, and
  2. On a direct patient care level, involving parents in systematic monitoring, identification, and reporting changes in their children's health status.
• Project Update: Phoenix Pediatrics continues to advance the medical home by empowering families. The "Child Health Status Assessment" tool has been developed that provides parents with a means of documenting the daily "norms" for their child and guides them through a comprehensive assessment as their child's condition changes. Phoenix Pediatric has also developed a system to assist families in tracking their child's daily care, have enacted a family focus group to discuss the quality indicators of a medical homes, and have developed the "Parent Empowerment Checklist for Success".

• Project Director: Judith Palfrey, MD
  Location: Children's Hospital Boston/Boston, Massachusetts
• The PACC seeks to address the major difficulties families face in accessing community-based, coordinated, and family-focused care for their CSHCN by fully implementing medical homes. This project will demonstrate that by further enhancing the medical homes at each of the project sites, real time implementation of a community-based, comprehensive approach to family/professional partnerships will be accomplished.
• Project Update: The PACC continues their many training programs, data collection, and family support. Linking Hands is a resident training program that allows residents to see CSHCN in their home environment. "Office Practice Training" sessions are conducted at their 6 pediatric offices which orient and train staff on techniques to better serve CSHCN and their families. A community resource coordinator has been hired to assist with planning activities, which have included in the past, summer picnics, an Art and Music Therapy Fall Festival, and a student volunteer program to provide companionship to CSHCN. The PACC continues to work with insurance companies and the state Medicaid agency to demonstrate how care coordination effects overall costs and satisfaction for CSHCN.

• Project Director: Mary Beth Bruder, PhD
  Location: Farmington, CT
• The goal of this project is to develop a medical home model and then pilot it in North Central Connecticut. First, the current status of medical homes for CSHCN will be determined through family and early intervention service coordinator surveys, case studies and focus groups. From the results of the investigation, a medical home model will be developed. Training will be provided to replicate the model throughout Connecticut. Eventually, the project anticipates disseminating the model nationwide.
• Project Update: Project Connect is developing a medical home model. The aim of the project is to train pediatricians, health professionals, and families on this model. Their hope is to eventually expand their model throughout the State of Connecticut. The project is currently working on a directory of medical homes in the state and developing training material.

• Project Director: W. Carl Cooley, MD
  Location: Hood Center for Family Support/Lebanon, NH
• The RMHIP fosters the development of community-based medical homes for CSHCN by equipping pediatric practices in Vermont and New Hampshire with a continuous improvement process, a partnership with parents, a linkage to community resources, and the capacity for enhanced care coordination.
• Project Update: This project continues to use a team approach to provide a medical home to CSHCN in rural New Hampshire, Vermont, and Main. The "core teams" are working in the 6 New England practices to develop a "RMHIP Tool Kit" that will teach other pediatricians how to implement medical homes in their own practices. A Medical Home Index is also in development that proposes to measure the capacity to which a medical home is provided in primary care practices. Other activities include developing the role of the care coordinator in primary care, plans for a Medical Home Project Retreat in the Spring, and continued training and educational opportunities in the community.

• Project Director: Robert Dimand, MD
  Location: University of California David Health System/Sacramento, CA
• The primary purpose of the project is to demonstrate and evaluate the ways in which telemedicine and telehealth technologies can be used as tools in developing a medical home to CSHCN and their families in a medically-underserved rural community. The project foresees that telemedicine will be an effective tool in building new partnerships and implementing new systems for managing and coordinating care.
• Project Update: The first year of the program focused on installation of the interactive video-conferencing equipment and determining the needs of the community. Staff has been hired to coordinate the clinical consults and been trained in documentation and reporting requirements, as well as the safe and effective use of the telemedicine equipment. Specialists in pulmonology and cardiology are teaching the telemedicine staff to measure the effectiveness of using e-stethoscopes in evaluations of patients conducted through video.

Adobe Acrobat Reader is available free from the Adobe web site.

Last Updated December 28, 2007