Resources & Linkages

Families often look to their physicians for guidance and support, mainly in the form of collaborative problem solving and resource management. It is important to be aware of, refer, and even partner with community organizations that offer ancillary services of benefit to patients and families. In addition to the resources listed on each of the State Pages, following are key organizations and tools to consider. Please note that this page provides additional resources as to what is provided in the Resources & Linkages section of the Building Your Medical Home toolkit.

National Resources

Center for Mental Health Services Mental Health Services Locator
This locator provides comprehensive information by state about mental health services and resources and is useful for professionals, consumers and their families, and the public.

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Early Intervention Program for Infants and Toddlers with Disabilities (Part C of the Individuals with Disabilities Act IDEA)
Early Intervention Program for Infants and Toddlers with Disabilities (Part C of IDEA) is a federal grant program that assists states in operating a comprehensive statewide program of early intervention services for infants and toddlers with disabilities, ages birth through 2 years, and their families. National Early Childhood Technical Assistance Center supports the national implementation of the early childhood provisions of the Individuals with Disabilities Education Act (IDEA).

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Family to Family Health Information Centers (F2F HICs)
F2F HICs providine family friendly and culturally sensitive health care information to families in order to help them make good health care decisions. F2F HICs are run by experienced parents, and supported by private and public funds.

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Healthy Child Care America—State Contact Locator
With the help of many state stakeholders, Healthy Child Care America has identified key contacts in each state. Contacts that you will find include CCHCs, ECMHs, AAP Chapter Child Care Contacts, CCDF State Administrators, Child Care Resource and Referral Agencies, ECCS Coordinators, Licensing Contacts, and Professional Development contacts. Visit the HCCA Web site to learn about the role of a child care health consultant. If you believe the information listed on the state contact Web page of the HCCA Web site is incorrect, e-mail childcare@aap.org with the correct information.

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Help Me Grow National
Help Me Group National, a system that helps to connect at-risk children with the services that they need, has launched a Web site, including an interactive map of HMG affiliate states.

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Medicaid/CHIP
This Web site features a toolkit  to assist organizations playing a critical role in increasing awareness and understanding of children’s health insurance programs and ultimately driving eligible parents and guardians to apply for coverage on behalf of their uninsured children. State information and resources regarding Medicaid and the Children’s Health Insurance Program (CHIP) are available at online or 877/KIDS-NOW (877/543-7669).

  • Medicaid.gov
    This Web site is the first federal government Web site devoted to Medicaid and the CHIP, including federal policy guidance, lists of pending and approved waivers, highlights of the Affordable Care Act implementation efforts, and state-specific program information and data.

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National 211
2-1-1 is an easy to remember telephone number that connects people with important community services and volunteer opportunities While services that are offered through 2-1-1 vary from community to community, 2-1-1 provides callers with information about and referrals to human services for every day needs and in times of crisis.

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Pre-Existing Condition Insurance Plan (PCIP)
The PCIP program is an option for children and adults with pre-existing conditions to attain health insurance coverage. The state-based PCIP program was established under the Affordable Care Act, and is for children and adults who are US citizens, have been uninsured for at least six months and have a pre-existing condition that has prevented them from attaining health insurance coverage. The PCIP is a transitional program available for children and adults in all 50 states and the District of Columbia who have been denied health insurance because of a pre-existing condition.

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Title V
Title V of the Social Security Act is one of the largest federal block grant programs. States and jurisdictions use Title V funds to design and implement a wide range of maternal and child health programs that meet national and state needs. Your state Title V program is a resource on how to access available services in your community. State maternal and child health agencies also maintain a toll-free hotline to aid families in obtaining information about State Title V programs and providers.

  • Collaboration and Action to Improve Child Health Systems: Toolkit for State Leaders PDF
    This Health Resources and Services Administration (HRSA)/ Maternal and Child Health Bureau (MCHB) toolkit is a resource that provides users with an approach to mapping the child health system in a state. This allows state leaders to better envision the flow of services and funding that support access to care for children and families and identify opportunities for improvement. The toolkit contains system diagrams, discussion questions, and sample scenarios on topics such as:
    • the Title V agency role in ensuring child health;
    • Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT) mandates on collaboration and outreach to families;
    • medical and dental homes;
    • EPSDT screening visits; linkages, case management, and care coordination;
    • care for children with special needs;
    • Medicaid managed care; and
    • public-private and interagency collaboration.

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State Resources

State Resources
Each of the State Pages on the National Center Web site features local resources, organizations, and contacts regarding medical home on the community level. Please visit the State Pages section to learn more.

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Building Medical Homes: Lessons From Eight States with Emerging Programs
The Commonwealth Fund—December 2011
The eight states profiled in this report—Alabama, Iowa, Kansas, Maryland, Montana, Nebraska, Texas, and Virginia—are at different stages in the development and implementation of a medical home program and have relied on different strategies to encourage primary care providers to adopt the model, including developing state medical home qualification standards instead of adopting national standards.

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State Resources for Prevention and Early Identification of Mental Health and Substance Use Conditions
A core component of the Medicaid program is the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit which ensures that the health care needs of children and youth are addressed to maximize their growth and development. The Center for Medicaid and CHIP Services issued an Informational Bulletin in March 2013 to help inform states about resources available to help them meet the needs of children under EPSDT.

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Speakers Kit on Early Childhood Systems
American Academy of Pediatrics (AAP)
AAP has consolidated resources developed for the Building Bridges Among Health & Early Childhood Systems project partners in order to encourage other state teams to help guide efforts to improve early brain and child development within state early childhood systems.

 

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Tools for the Office

Building Partnerships Between Provider Practices and Community Organizations
Community organizations can help provider practices navigate local resources to better support patients. A new brief from Center for Health Care Strategies, Inc outlines considerations for practices looking to develop community partnerships.

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Community Services Locator
The Community Services Locator is an online directory for finding services for children and families in the communities in which they live. The locator, produced by the MCH Library, may be used by service providers and families to find available health, mental health, family support, parenting, child care, and other services.

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Health Care Language Services Implementation Guide
This guide provides practical, ground-level suggestions for how health care organizations and providers can implement language access services (LAS) for individuals with limited English proficiency (LEP) based on the National Standards for Culturally and Linguistically Appropriate Services in Health Care recommended by the Office of Minority Health (OMH), DHHS. The guide is designed to meet the needs of health care organizations of all sizes and is intended to be patient-centered and family focused.

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Local List of Possible Community Resources for Pediatric Practices
AAP Practice Management Online (PMO) (Member benefit to all AAP members)
This sample office document can be used to provide families with the names and contact information of local referral sources and family groups so the information is readily available when needed.

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Sample Resource Guides

Connecting Those at Risk to Care—A Guide to Building a Community “HUB” To Promote a System of Collaboration, Accountability, and Improved Outcomes PDF
Agency for Healthcare Research and Quality (AHRQ)
This guide is intended to help improve the system by which at-risk individuals within a community are identified and connected to appropriate health care and social services. This guide may be of interest to federal, state, and local governmental agencies and community-based organizations, such as safety net clinics, hospitals, public health departments, and charitable organizations.

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Family Village
A global community that integrates information, resources, and communication opportunities on the Internet for persons with cognitive and other disabilities, their families, and those that provide services and support. This site offers informational resources on specific diagnoses, communication connections, adaptive products and technology, adaptive recreational activities, education, worship, health issues, and disability-related media and literature.

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Illinois Life Span
This organization provides a statewide information and advocacy coordination system for people with developmental disabilities. The Arc of Illinois Family Manual for Transition resource to assist families of young adults with developmental disabilities with the transition from the school system and services for children to the world of work and adult services, is available on the Illinois Life Span Web site.

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Special Needs Resource Directory of Southwest Ohio
Center for Infants and Children with Special Needs, Cincinnati Children's Hospital Medical Center
A n extensive, one-stop resource directory to assist caregivers of children with specialized health care needs. The goal of the Special Needs Resource Directory is to provide comprehensive Web-based information — assembled in one convenient location — to both parents and professionals. The resource directory is designed to be a quick, easy reference for all parents and medical professionals, regardless of computer experience.

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Promising Practices

Medical Home Interview Videos New
Developed by the National Center for Medical Home Implementation

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Defining the Medical Home: The Oregon Experience
J Am Board Fam Med. November 2012. 25:6869-877
In 2009, the state of Oregon convened a public, legislatively mandated committee charged with developing PCMH measures. This article reports on the process of, outcomes of, and lessons learned by this committee.

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Hawaii Child Health Success: Early Childhood Comprehensive Systems Partnerships
Association of Maternal and Child Health Programs
This article discusses the success of the Hawaii Early Childhood Comprehensive Systems (ECCS) project, which has benefited heavily from the established relationships with key partners that are committment to the vision that all children will be safe, healthy, and ready to succeed and the ability to work through each agencies’ missions to this end.

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New Opportunities for Integrating and Improving Health Care for Women, Children, and Their Families PDF
The Commonwealth Fund and the Association of Maternal and Child Health Programs (AMCHP), 2012
This issue brief highlights “the efforts of Colorado, Florida, Ohio, and Vermont to integrate health care services for low-income women and children, especially through state Title V and maternal and child health programs.”

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Virginia Asthma Plan 2011–2016
The Virginia Asthma Coalition (VAC) is a group of organizations and individuals devoted to reducing the morbidity and mortality associated with asthma. This statewide strategic plan and provides a call to action for asthma in Virginia.

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Web-based Training for Standardized Illinois Early Intervention Referral Form
The Illinois Chapter of the American Academy of Pediatrics (ICAAP) has developed a Web-based training for implementation of the Standardized Illinois Early Intervention Referral Form PDF. The module teaches the importance of the form as well as how to complete it. These forms and the Web-based training may be of interest to a national audience of Part C Coordinators and providers who interact with Early Intervention. However, the intended audience is Illinois Early Interventionists. The forms can be adapted by other states with written permission from ICAAP. Submit requests to Jodie Bargeron, Manager of Medical Home Initiatives.

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