Medical Homes in Pennsylvania
This page is designed to keep you informed about events and activities happening in Pennsylvania that will help improve access to medical homes for children with special health care needs (CSHCN).

Medical Home Initiatives
This section provides information on state medical home initiatives/programs. States that are a part of the mentorship network will have a "Promise to the State" which outlines how they will achieve ensuring that all children have a medical home by 2010. This is based on the Healthy People 2010 goals which is a 10 year action plan to achieve and measure success for all CSHCN.

Pennsylvania Medical Home Team Contact:

Name: Molly Gatto - Project Coordinator, EPIC Integrated Care PA Chapter, AAP
Contact: Phone: 484-446-3000 | Email: mgatto@paaap.org

MCHB Medical Home Grant: Educating Practices in Community Integrated Care
Project Period: July 1, 2004 – June 30, 2008
Purpose: The purpose of EPIC IC is to improve the quality of life for children with special health care needs (CSHCN) and their families by continuing to build sustainable MH teams in primary care practices and health care systems throughout Pennsylvania. EPIC IC will focus on providing MH and care coordination (CC) services for families in underserved communities, increasing the integration of family advisors into the practice team, and assuring the availability of care coordination for children and families, especially youth in transition.

EPIC IC is a collaborative effort of the Pennsylvania Department of Health Division of Special Health Careprograms (DOH Title V), family organizations (Family Voices, Parent to Parent), and the PA Chapter of the AAP. EPIC IC Medical Home project is based on the Educating Physicians In their Communities (EPIC) model. The EPIC IC is a statewide provider education program using office based change as the key to improving the care provided to Children with Special Health Care Needs (CSHCN).

MCHB Medical Home Grant:
Purpose: 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.

Educating Physicians in Community Integrated Care - Medical Home Project progress report
Goals/Objectives: The EPIC IC will establish a training program for primary care providers and their office staffs on how to create a medical home for children with special health care needs. Creating a medical home is organized around the seven components of care that are: accessible, family-centered, comprehensive, continuous, coordinated, compassionate and culturally competent.

Nineteen practice teams across the state have been recruited to engage in a process of quality improvement in the care of their special needs patients. Teams are comprised of a clinician, staff member and a family representative. These teams attended a two day training conference and participate in monthly conference calls on a medical home concept or topic that the practices want to address. Each practice team has developed and started to implement a quality improvement cycle based on needs identified by the practice. These nineteen teams will also provide in-office or grand rounds presentations based on the basic elements of the medical home to physicians and office staff.

For more information on the EPIC IC Medical Home project, go to: www.paaap.org/mod.php?mod=userpage&menu=807&page_id=14

EPIC Presentations available on the medical home state page:
EPIC Overview | EPIC Family-Centered Care | EPIC Care Coordination

Educating Medical Professionals in the Community (EMPC)
Creating Medical Homes for Young Adults with Special Healthcare Needs

History
In summer 2004, the PAFP Foundation was awarded a two-year grant by the PA Developmental Disabilities Council to establish a training and quality improvement program to enhance the quality and accessibility of healthcare for young adults with special healthcare needs.

The Project -
Ten family medicine practices from across the state will serve as medical home demonstration sites. Those physicians and staff, with the support of PAFP's Medical Home Coordinator and the EMPC Advisory Council, will strengthen their practices' capacity to support adults with special healthcare needs in a medical home.

Medical Home Project Kick Off Meeting
March 31, 5:30 - 9pm and April 1, 7:45 am - 4pm.
A conference for physicians and practice staff to learn about medical home implementation and supporting persons with special needs. The conference is designed for staff of project demonstration sites and for practices wanting to learn more about the project.

Contact Info
Stephanie DeMuro, Medical Home Coordinator: sdemuro@pafp.com or 1-800-648-5623.

Related Grant Initiatives
This section provides information on current state grants that are working on medical home initiatives. This includes the grant abstract as well as key contacts for the grant.

Dyson Community Pediatrics Training Grant
The Children's Hospital of Philadelphia Pediatric Residency Program
Through The Initiative, the Community-Based Pediatrics and Advocacy Program (CPAP) at The Children's Hospital of Philadelphia teaches residents to become pediatricians who are as comfortable and competent in their role as child advocates as they are in the medical practice; who can be effective advocates for an individual child and family, as well as all children in their community; and who can work in partnership with private and public community-based agencies to promote the well-being of children. Through this educational process, we integrate an expanded focus on community-based pediatrics and advocacy through the Hospital.

The ultimate goal of the Dyson Initiative is the development of pediatric professionals with greater skills and interest in community-based medicine, advocacy, and the capacity to improve the health of children in their communities. Here you can learn how diverse programs around the country are educating residents about community pediatrics and fostering practical community experiences. www.aap.org/commpeds/cpti/grantees.htm

Hemophilia Grant
Purpose: The purpose of this project is to provide regional services, through the Core Center, to support access to and provision of culturally sensitive, family centered, multi-disciplinary comprehensive care for persons with bleeding disorders, through the existing effective network of Region III HTCs. Hemophilia, an inherited bleeding disorder, results from a deficiency of coagulation factor VIII or factor IX and von Willebrand’s Disease (VWD) is an inherited bleeding disorder resulting from decreased vonWillebrand protein. These bleeding disorders result in both spontaneous and trauma-induced bleeding. Region III is comprised of 15 federally funded hemophilia treatment centers (HTCs) in Delaware, Maryland, Pennsylvania, Virginia, West Virginia, and the District of Columbia. Each HTC is a specialty, prevention, diagnostic and treatment program with the goal of providing state-of-the-art medical and psychosocial evaluation and care, dental, education, genetic, research, and support services for children, adolescents, and adults with bleeding disorders, including women, minorities, and the geographically isolated. Care is provided in a preventive framework aimed at decreasing complication risks and minimizing lifestyle disruption.

Partners in the State
This section provides information on who in the state (individuals and agencies) are working together to create medical homes for children.

American Academy of Pediatrics (AAP) Chapter: www.paaap.org/

American Academy of Family Physicians (AAFP) Chapter: www.pafp.com/

Title V CSHCN Program - Bureau of Family Health Services and programs for: pregnant and parenting women, children, CSHCN, adolescents, and adults: www.health.state.pa.us/

Title V Block Grant to States
Title V of the Social Security Act is one of the largest Federal block grant programs. It leads the nation in ensuring the health of all mothers, infants, children, adolescents, and children with special health care needs (CSHCN). Title V is administered by the Maternal and Child Health Bureau (MCHB) as part of the Health Resources and Services Administration, U.S. Department of Health and Human Services.

Title V and Children with Special Health Care Needs
MCHB Objective: Support development and implementation of comprehensive, culturally competent, coordinated systems of care for the estimated 18 million U.S. children who have or are at risk for chronic physical, developmental, behavioral or emotional conditions and who also require health and related services of a type or amount beyond that required by children generally.

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 the hearing loss, prompt enrollment in appropriate Early Intervention, link newborns to a medical home and strive to eliminate geographic and financial barriers to service access.

Name: Arthur Florio, Program Administrator
Contact: Tel: (717) 783-8143 | Fax: (717) 705-9386
Email: aflorio@state.pa.us

Early Intervention/Part C Coordinator: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 age 2 years, and their families.

Name: Maureen Cronin, Part C Coordinator
Contact: Phone: (717) 783-7213 | Fax: (717) 772-0012 | Email: mcronin@state.pa.us
Web Site: www.dpw.state.pa.us/child/earlyintervention/default.htm

Section 619/ Preschool Grants Program of the Individuals with Disabilities Education Act (IDEA). This program provides free appropriate public education (FAPE) for children, ages 3 through 5 years, with disabilities:

Name: Richard Price, Chief
Contact: Phone: 717/ 783-6882 (Price) | Phone: 717/ 783-6889 (Beck) | Fax: 717/ 783-6139
Email: rprice@state.pa.us
Web Site: www.pde.state.pa.us/special_edu/site/

State Interagency Coordinating Council (ICC) Chairs:
The ICC 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.

Name: Tracey Khalife, ICC Co-Chair
Phone: (570) 836-1995
Email: khalife@epix.net

Janice Matthew, ICC Co-Chair
Contact: Phone: (412) 323-4088 | Fax: (412) 323-3965
Email: drjmatthew@aol.com
Web Site: www.pattan.k12.pa.us/

Resources/Documents
Sample Forms available on the Pennsylvania medical home state page: Microsoft Word

• Abbreviated Medical Home Index
• Common ICD-9 Codes Microsoft Excel
• Special Needs ICD-9 Codes Microsoft Excel
• CSHCN Screening Tool - CAHPS
• CSHCN Screening Tool - SLAITS
• Documentation Guidelines
• EPIC Problem Based Learning Case Studies
• Evaluation and Management CPT Codes
• Patient Medical Summary
• Progress Note
• Referral Fax Back Form
• Severity Scoring Scale - Phoenix Pediatrics
• Tips on Preparing to See the Doctor

• EPIC Overview PPT available

Screening Initiatives
This section provides information on surveillance and screening initiatives in the state.

Developmental Surveillance and Screening Policy Implementation Project (D-PIP)
Children's Hospital of Pittsburgh Primary Care Center from Pittsburgh, PA is participating in the Developmental Surveillance and Screening Policy Implementation Project (D-PIP). The D-PIP has selected 17 practices from across the United States to implement the AAP policy statement (scheduled for publication in July 2006) “Identifying Infants and Young Children with Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening” to 1) determine if the algorithm is efficiently and effectively implemented into pediatric practice; 2) recognize strategies for implementing the algorithm; and 3) examine outcomes of implementation. Following the project, information and outcomes will be shared with pediatric clinicians and other health care professionals who are seeking to improve the delivery of developmental surveillance and screening.

Additional information on the D-PIP is available at: www.medicalhomeinfo.org/screening/DPIP.html

State Newborn Screening & Genetics Programs: genes-r-us.uthscsa.edu/resources.htm

• State Newborn Screening Program Links
• State Genetics Program Links
• Regional Genetics and Newborn Screening Collaborative Links
• Newborn Screening State Contact Fact Sheet

Family Corner
Advocacy and Support Organizations
The Child Advocacy Project of Philadelphia: www.cap4kids.org/philadelphia/
Within this site you will find a user-friendly, comprehensive listing of many social service agencies that exist to improve the lives of families that need our help the most. The Parent Handouts and sample advocacy letters are the backbones of this project. The Parent Handouts are broken down by category and within each handout, you will find a description of the social service agency, their address, and a phone number. You may also find a link to the agencies web site that you can access and learn more about that agency. You may also download a PDA version of these handouts for quick access to the descriptions of various agencies and their contact information.

Family Voices: www.familyvoices.org/st/PA.htm
Partnering with professionals and families to advocate for health care services that are family-centered, community-based, comprehensive, coordinated and culturally competent.

NAMI of Pennsylvania (National Voice on Mental Health): namipa.nami.org/
Education, advocacy and support for persons with brain disorders (mental illnesses) and their families.

Parent to Parent: www.parenttoparent.org/
Parent to Parent of Pennsylvania is a network created by families for families of children and adults with special needs. They connect families in similar situations with one another so that they may share experiences, offer practical information and/or support.

Parent Education Network: www.parentednet.org/
PEN is Pennsylvania's statewide Parent Training and Information Center. Much of the information included in this site is designed to support Pennsylvania parents of children with special needs, but information and links are included on Federal Special Education, National Disability Issues and Resources, Special Education Legal Links, Transportation, and Travel that will also pertain to parents and individuals with disabilities in other states.

The Mentor Parent Program, Inc: www.mentorparent.org/
The Mentor Parent Program is a community-based parent project created in 1989 by parents of children with special needs to support, assist and provide expertise to parents in rural northwest Pennsylvania.

Resources and Information
Early Hearing Detection & Intervention (EHDI) Information for Parents:
Description of EHDI Program
www.medicalhomeinfo.org/screening/State/pennsylvania.html

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

The Association for Retarded Citizen (Arc) Family Resource Guide http://www.thearc.org/familyguide/pennsylvania.doc
This guide is written for families raising children with mental retardation and related developmental disabilities. It tells families about benefits, supports and services in their state that might help their child.

State Resources on the Internet: www.medicalhomeinfo.org/states/index.html#res

Note: The information provided on the state pages was submitted by the state medical home teams.As this is not an exhaustive list, please let us know if you have additions for your state resource page. You can contact us at: medical home@aap.org.

http://www.medicalhomeinfo.org/states/state /pennsylvania.html

Last Updated August 10, 2006