Patient-Centered Medical Home An Overview and Colorado’s Landscape
ClinicNET and the Colorado Rural Health Center have released a brief on the patient centered medical home (PCMH) to support the model and provide services to assist clinics in pursuing certification or designation. It outlines the fundamentals of the PCMH, emphasizes the belief that "quality care is culturally and linguistically appropriate, and is provided at an appropriate health literacy level," and offers resources to help safety net clinics achieve PCMH status.
Study—Colorado Children's Healthcare Access Program (CCHAP): Helping Pediatric Practices Become Medical Homes for Low-Income Children
This study, conducted by Commonwealth Fund, highlights the CCHAP, a nonprofit organization created to address barriers that have prevented private pediatric and family practices from accepting children enrolled in Medicaid and providing them with a medical home. CCHAP helps pediatric practices to meet the state's medical-home certification and receive enhanced reimbursement from Medicaid, while providing them with an array of support services, including care coordination, a resource hotline, and billing assistance. CCHAP also connects practices and families to community organizations and state and county agencies, and trains practice staff on how to identify children's needs and refer families to appropriate resources. A recent evaluation shows children covered by Medicaid and with a medical home in a private pediatric practice supported by CCHAP visit the emergency department less often, have more preventive care visits, and are less expensive for the state Medicaid program than children in non-CCHAP-affiliated practices.
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Medical Home Chapter Champions Program on Asthma (MHCCPA)
Through the support of the Merck Childhood Asthma Network, Inc. (MCAN), the MHCCPA facilitates the dissemination of best practices and advocacy related to the implementation of the National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines within the medical home framework. Program goals include identifying a champion at the AAP chapter and/or state level(s) to educate/mentor providers in their communities, in addition to increasing advocacy efforts, for implementation of the NHLBI guidelines within the context of a medical home. If you would like more information about the project, would like to be connected with your chapter/state's champion 
, or are interested in serving as a chapter champion if your chapter/state does not currently have one, contact Suzi Montasir, MPH, Program Manager at 847/434-4311 or fill out the Contact Us form.
Children's Health Insurance Program Reauthorization Act (CHIPRA) Grants—Cycle II
Colorado is one of 23 states that received CHIPRA Cycle II grants to for efforts to identify and enroll children eligible for Medicaid and CHIP. The grants will build upon the HHS Connecting Kids to Coverage Challenge to find and enroll children and support outreach strategies that have proven successful.
Children's Health Insurance Program Reauthorization Act (CHIPRA) Grants—Cycle I
Colorado is a lead on one of 10 CHIPRA grants, representing single-state projects and multi-state collaborations, from HHS to improve health care quality and delivery systems for children enrolled in Medicaid and the Children's Health Insurance Program (CHIP). The money will help states implement and evaluate provider performance measures and utilize health information technologies such as pediatric electronic health records and other quality improvement initiatives.
LEND Programs Receive Funding to Improve the Health of Children with Special Health Care Needs
The Health Resources and Services Administration (HRSA) has awarded $28.3 million to 43 Leadership Education in Neurodevelopmental and Other Related Disabilities (LEND) programs, including the program at the University of Colorado HSC, to help improve the health of infants, children, adolescents and young adults with neurodevelopmental and other related disabilities, including autism spectrum disorders. LEND programs prepare trainees from a wide variety of professional disciplines to assume leadership roles, ensure high levels of interdisciplinary clinical competence, and enhance the ability of clinicians to diagnose, treat, and manage complex disabilities in youth and adolescents.
State Implementation Grant (D70) for Improving Systems of Services for Children and Youth with Special Health Care Needs (CYSHCN)—Colorado State Department of Public Health and Environment—Abstract 
Grant Period: 2008-2011
Address: 4300 Cherry Creek South Dr., Denver, CO 80246-1523
Program Director: Kathy Watters
Phone: 303/692-2418 | E-mail: kathy.watters@state.co.us
Colorado Accountable Care Collaborative (ACC)
The goal of the ACC is part of the Department of Health Care Policy and Financing's Medicaid reform effort and aims to improve health outcomes for Medicaid clients through a coordinated, client-centered system while supporting providers and protecting safety-net providers. It is envisioned to consist of a statewide data and analytics organization and a number of regional care coordination organizations. These regional organizations will be charged to offer care-coordination services and to support the local participating providers and clients in the regions. The Request for Proposals will go out in summer 2010, and the Department will implement the program later in 2010 starting with 60,000 clients.
Consortium to Advance Medical Homes for Medicaid and CHIP Participants
National Academy for State Health Policy (NASHP)—January 2011
Fifteen state teams were brought together by the NASHP to form a Consortium to Advance Medical Homes for Medicaid and Children's Health Insurance Program (CHIP) Participants. These states will work together to develop and implement policies that increase Medicaid and CHIP program participants' access to high performing medical homes. This past spring, the kick-off meeting was held for the 15 participating states (Alabama, Colorado, Maryland, Massachusetts, Michigan, Minnesota, New Mexico, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, Rhode Island, Vermont and Washington); the blog post—Constructive Ideas from Medical Home Builders—features an interview with NASHP policy analyst Jason Buxbaum about the Consortium states' medical homes projects.
Colorado Medical Home Initiative
The Colorado Initiative is a systems-building effort to promote quality health care for all children in Colorado. Bringing together a group of more than 40 people representing various agencies, families, hospitals, organizations and policy-makers, the Colorado Medical Home Initiative is dedicated to building a sustainable system that delivers quality health care for all children. Positioned within the Colorado Department of Public Health and Environment as the lead agency, the Colorado Medical Home Initiative is a neutral facilitator in identifying barriers while promoting solutions in developing a quality-based system of health care for children.
The Safety Net Medical Home Initiative
In May 2008, The Commonwealth Fund, Qualis Health and the MacColl Institute for Healthcare Innovation at the Group Health Research Institute initiated a demonstration project to help safety net primary care clinics become high-performing patient-centered medical homes (PCMHs). Five Regional Coordinating Centers were selected to participate in the demonstration project, and each partnered with 12-15 safety net clinics in their state. These collaboratives will receive technical assistance on practice re-design topics such as enhanced access, care coordination, and patient experience. They will also receive funding to support a Medical Home Facilitator (who will lead clinic-based quality improvement projects) and other activities. The work of the Regional Coordinating Centers began in April 2009 and the Initiative will continue through April 2013.
- Colorado Community Health Network
- Paying for the Medical Home—Payment Models to Support Patient-Centered Medical Home
Transformation in the Safety Net
Operating as a medical home requires increased non-reimbursed activity (eg, care team meetings, patient self-management education, care coordination, data analysis, communication with other clinicians) and care management. In order for patient-centered medical home (PCMH) practice transformations to be sustainable, there must be payment reform to incentivize high-value, first-contact, primary care, and support medical home costs that are traditionally not reimbursed (eg, non face-to-face encounters). This publication provides an introduction to a series of policy briefs focusing on payment reform opportunities to support and sustain the medical home.
State Initiatives in Patient-Centered Medical Homes
The Council of State Governments
The majority of state Medicaid programs are testing models of coordinated medical care to improve quality and reduce costs, particularly for patients wit h multiple chronic illnesses. This brief includes descriptions of eleven states' pilot programs or authorizing legislation including Colorado.
The Assuring Better Child Health and Development (ABCD) Program
The ABCD Program is funded by the Commonwealth Fund, administered by National Academy for State Health Policy (NASHP), and designed to assist states in improving the delivery of early child development services for low-income children and their families by strengthening primary health care services and systems that support the healthy development of young children, ages 0-3. The program focuses particularly on preventive care of children whose health care is covered by state health care programs, especially Medicaid. Since 2000, the ABCD program has helped twenty-seven states create models of service delivery and financing through a laboratory for program development and innovation.
Rural Health Information Technology Grants
Funded through HRSA, rural health networks across the nation will receive more than $11.9 million to support their adoption of HIT and certified Electronic Health Records (EHRs). Each of 40 grantee organizations will receive about $300,000 to purchase equipment, install broadband networks and provide training for staff. In Colorado, the grantees include the Huerfano County Hospital District and the Telluride Medical Center Foundation. The pilot program was developed as a result of the President's Rural Health Initiative.
Health Resources and Services Administration (HRSA) in Your State
HRSA in Your State offers overviews of HRSA programs and current information, such as the number and amount of grants awarded down to the County level. It also provides state-specific information about health centers, National Health Service Corps members and the communities they serve, and the number of participating providers through the 340B program.
Early Childhood Comprehensive Systems (ECCS) State Contacts
The Maternal and Child Health Bureau (MCHB) launched the State Maternal and Child Health Early Childhood Comprehensive Systems (ECCS) Initiative to implement the MCHB Strategic Plan for Early Childhood Health. The purpose of ECCS is to support states and communities in their efforts to build and integrate early childhood service systems that address the critical components of access to comprehensive health services and medical homes; social-emotional development and mental health of young children; early care and education; parenting education, and family support. For additional information, you can look up your state's ECCS Grantee Contact or Grantee Web site.
AAP: Community Pediatrics Grant Database
The Community Pediatrics Grant Database archives previously funded Community Pediatrics grant projects, including those funded through the CATCH Program, the Healthy Tomorrows Partnership for Children Program, the Community Pediatrics Training Initiative, and the Healthy People 2010 Chapter Grants. The database is searchable by seven major categories: target population; health topic; state/territory; project activity; AAP program; AAP district; and project year. Members of the AAP can obtain grantee contact information by searching through the Member Center. If you are not an AAP member, but have questions please contact docbi@aap.org.
Funding Opportunities
This page houses information on funding opportunities from the AAP and other organizations, as well as links to other key funding contacts and resources.
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This section provides information on state organizations that play a role in implementing various aspects of medical home, and includes links to their Web sites and contact information.
American Academy of Pediatrics (AAP) Chapter—Colorado
AAP chapters are organized groups of pediatrician members and other health care professionals working to achieve AAP goals in their communities. Please contact your local chapter for additional state resources.
American Academy of Family Physicians (AAFP) Chapter—Colorado
AAFP represents more than 94,000 family physicians, family medicine residents, and medical students.
Family Voices Chapter—Colorado
Family Voices aims to achieve family-centered care for all children and youth with special health care needs (CYSHCN) and/or disabilities. Through a national network of chapters, they provide families with tools to advocate for improved public and private policies, and build partnerships among professionals and families.
Family-to-Family Health Information Centers (F2F HICs)
F2F HICs are non-profit organizations that help families of CYSHCN and the professionals who serve them. F2F HICs are typically staffed by parents of CYSHCN who understand the issues that families face, provide advice, offer resources, and tap into a network of other families and professionals for support and information.
Family Voices Colorado
Address: 450 Lincoln Street Suite 100B, Denver, CO 80203
Phone: 303/733-3000 | Fax: 303/733-3344 | Toll-Free: 800/881-8272
Primary Contact: Christy Blakely
Title V Maternal and Child Health (MCH) Director
Title V Children with Special Health Care Needs (CSHCN) Director
Title V of the Social Security Act is the nation's oldest federal program to improve the health of all mothers, infants, children, adolescents, and CSHCN. Title V is administered by the federal Maternal and Child Health Bureau (MCHB) as a block grant to states to support core public health functions, such as care coordination and rehabilitation services.
Early Hearing Detection & Intervention (EHDI) Contact(s)
State EHDI programs promote universal newborn hearing screening, develop effective tracking and follow-up as a part of the public health system, promote appropriate and timely diagnosis of hearing loss, prompt enrollment in appropriate early intervention, ensure a medical home for all newborns, and strive to eliminate geographic and financial barriers to service access.
State Newborn Screening & Genetics Programs
Early Intervention/Part C Coordinators
The 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.
State Section 619/Special Education for ages 3-5 Coordinators
This program provides free appropriate public education (FAPE) for children, ages 3 through 5 years, with disabilities.
State Interagency Coordinating Council (ICC) Chairs
This program advises appropriate agencies on the unmet needs in early childhood special education and early intervention programs for children with disabilities, assists in the development and implementation of policies that constitute a statewide system, and assists all appropriate agencies in achieving full participation, coordination, and cooperation for implementation of statewide system.
Children's Health Insurance Program (CHIP) Directors
CHIP is Title XXI of the Social Security Act and is a state and federal partnership that targets uninsured children and pregnant women in families with incomes too high to qualify for most state Medicaid programs, but often too low to afford private coverage. Within federal guidelines, each state determines the design of its individual CHIP program, including eligibility parameters, benefit packages, and administrative procedures. The Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009 re-authorized the program through FY 2013, and includes many incentives for states to find and enroll more eligible children in both Medicaid and CHIP. CHIPRA also includes quality provisions that aim to monitor and improve care delivered through the Medicaid and CHIP programs. Each state does have a CHIP program, and the names of these programs differ from state to state. To find information on health coverage programs in your state, visit the InsureKidsNow.gov Web site.
National Association of State Health Policy (NASHP)—Colorado CHIP Fact Sheet
This fact sheet provides a baseline snapshot of state CHIP programs before the enactment of the CHIPRA and the Patient Protection and Affordable Care Act (ACA).
Medicaid State Directors
(Select the SMD Directory on the left side of the site for the current list of Medicaid State Directors)
Medicaid is Title XIX of the Social Security Act and is a federal/state entitlement program that provides medical assistance to certain individuals and families with low incomes and/or special health care needs. Medicaid is of unique importance to children; together with the CHIP, Medicaid insures over 1 in 4 children in the United States, with millions more eligible but currently unenrolled. The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program is a critical component of Medicaid, which guarantees that children enrolled in Medicaid are screened for medical or developmental problems early, and that necessary treatments and services are provided. To find information on health coverage programs in your state, visit the InsureKidsNow.gov Web site.
- Medicaid State Reports—2011
The American Academy of Pediatrics, in partnership with the National Association of Children's Hospitals, has created fact sheets that explain the importance of the Medicaid program, and how children in every state rely on it for their health care.
Community Health Centers in the State
HRSA provides a searchable database of federally-funded health centers. Health centers provide care to those with or without health insurance including well-care check ups, treatment when sick, complete care during pregnancy, immunizations and checkups for children, dental care, prescription drugs, and mental health and substance abuse care.
Regional Extension Centers (RECs)
Health Information Technology RECs support and serve health care providers to help them quickly become adept and meaningful users of electronic health records (EHRs). RECs are designed to make sure that primary care clinicians get the help they need to use EHRs by providing training in adopting EHRs, guidance with implementation, and technical assistance as needed.
Colorado Medical Home Initiatve
The Colorado Medical Home Initiative began in 2001 in response to the Title V/Maternal and Child Health (MCH) national outcome measure, all children will receive comprehensive coordinated care within a Medical Home. The Colorado Initiative is a systems-building effort to promote quality health care for all children in Colorado. Bringing together a group of more than 40 people representing various agencies, families, hospitals, organizations and policy-makers, the Colorado Medical Home Initiative is dedicated to building a sustainable system that delivers quality health care for all children. Positioned within the Colorado Department of Public Health and Environment as the lead agency, the Colorado Medical Home Initiative is a neutral facilitator in identifying barriers while promoting solutions in developing a quality-based system of health care for children.
Health Care Program (HCP) for Children with Special Needs
House within the Colorado Department of Public Health and Environment, the HCP focuses on care coordination, developing improved systems of care, and providing specialty and diagnostic clinics throughout the State of Colorado.
JFK Partners
JFK Partners is a multifaceted interdepartmental program of the Departments of Pediatrics and Psychiatry of the University of Colorado Health Sciences Center. Designated as Colorado's University Affiliated Program by the Administration on Developmental Disabilities and as Colorado's Leadership Education in Neurodevelopmental Disabilities (LEND) Program by the MCHB, JFK Partners has strong collaborative relationships with numerous organizations that are a part of Colorado's developmental disability and special health care needs communities.
Colorado Children's Healthcare Access Program (CCHAP)
CCHAP is a non-profit organization devoted to ensuring that every child enrolled in Medicaid and Child Health Plan Plus (CHP+) receives comprehensive health care from a primary care provider – a medical home and all pregnant women covered by Medicaid or CHP+ receive comprehensive prenatal services.
Improving Performance in Practice (IPIP)
IPIP
is aimed at transforming the way healthcare is delievered by giving doctors the tools, systems and support they need to provide consistently high quality care to all patients, all the time. IPIP will provide in-office assistance to practices, improving quality of care, efficiency, and satisfaction for both patients and the healthcare team.
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Association of Maternal and Child Health Programs (AMCHP)—Colorado State Profile
These state profiles provide a snapshot of how the Maternal and Child Health Block Grant (Title V) works in specific states. The profiles detail the federal funds appropriated to each state, state match, specific programs funded, numbers of people receiving services and state health needs.
Early Childhood State Policy Profiles
National Center for Children in Poverty (NCCP)
NCCP’s Early Childhood Profiles were produced as part of the Improving the Odds for Young Children project. These comprehensive profiles highlight states’ policy choices that promote health, education, and strong families alongside other contextual data related to the well-being of young children.
Issue Brief: Implementing the Medical Home in Medicaid, CHIP, and Multistakeholder Demonstration Programs
American Academy of Pediatrics (Member access only)
This Issue Brief serves to provide guidance to AAP chapters working with states to implement medical home projects in Medicaid and CHIP, as well as multipayer demonstration programs. It also addresses a number of the policy questions that frequently arise in creating state supports for the medical home.
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Medical Home Data Portal—State Data Pages
Child and Adolescent Health Measurement Initiative
The Medical Home State Data Portal profiles provide a state’s medical home performance level for all children and children with special health care needs, based on data from the 2007 National Survey on Children's Health and the 2005/2006 National Survey of Children with Special Health Care Needs.
Child Health USA 2010
US Department of Health and Human Services, Health Resources and Services Administration
This report is the 17th edition of the annual statistical report that highlights the health status and service needs of America's children. The report contains easy-to-access graphs and charts summarizing significant indicators of children's health status, statistics, figures, and references.
America's Children: Key National Indicators of Well-Being, 2011
Federal Interagency Forum on Child and Family Statistics
The purposes of the report are to improve Federal data on children and families and make these data available in an easy-to-use, non-technical format. It organizes well-being indicators into seven sections: family and social environment, economic circumstances, health care, physical environment and safety, behavior, education, and health.
2010 KIDS COUNT Databook
Annie E Casey Foundation
This report is a national and state-by-state profile of the well-being of America's children available as an interactive databook, a complete PDF-format report , and on request, in print. Data and rankings on 10 key indicators of child well-being are available by state, county, and city.
State-at-a-Glance Chartbook on Coverage and Financing for Children and Youth with Special Health Care Needs
The Catalyst Center
The Online State-at-a-Glance Chartbook provides data on carefully selected indicators of health coverage and health care financing for CYSHCN. Using the online Chartbook, you can access data for your state and easily compare it with both national averages and other states' data.
National Healthcare Quality & Disparities Reports
Agency for Health Research and Quality (AHRQ)
50-State Demographics Wizard
National Center for Children in Poverty (NCCP)
This tool allows you to create custom tables of national- and state-level statistics about low-income or poor children. Choose areas of interest, such as parental education, parental employment, marital status, and race/ethnicity—among many other variables.
Adolescent Health Database
National Adolescent Health Information Center (NAHIC)
The NAHIC database includes national and state-level profiles of key measures of the health of adolescents and young adults. National-level data is available by gender and race/ethnicity and also state-by-state, with summaries, data tables, and guidance for using this data to improve the health of adolescents and young adults.
Medical Home Data Fact Sheet—January 2009
American Academy of Pediatrics
To inform key aspects of the pediatric medical home, the AAP has compiled a data fact sheet of summary statistics and facts from various AAP and public and proprietary sources. These data define the current state of pediatric care, and as the efforts surrounding the promotion and expansion of the pediatric medical home accelerate, the fact sheet will change to reflect this new picture.
Profile of Pediatric Visits—April 2010
American Academy of Pediatrics
This report is based on the most current available four years worth of NAMCS and MEPS data (2004-2007). The updated report includes annualized estimates by source of payment, patient age, physician specialty, well vs sick visit, office setting, practice ownership, physician employment status, and geographic location.
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AAP Child Health Informatics Center—State and Territory Specific HIT Resources
This page on the AAP AAP Child Health Informatics Center (CHIC) Web site allows you to identify pediatric specific HIT resources by state related to Meaningful Use, Regional Extension Centers, State Health Information Exchanges, and other important information.
Colorado Patient Navigator Training Program
A patient navigator is a member of the healthcare team who helps patients "navigate" the healthcare system and get timely care. Navigators work with patients to identify their barriers to healthcare and connect them to the resources they may need such as financial assistance, counseling, language translation or transportation. Courses are for patient navigators, social workers, parish nurses, CNA and other community health care workers.
Medical Home Presentations
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