Partners in Medical Home

Partners in Medical Home Overview

As described on our homepage, a medical home facilitates an integrated health system with an interdisciplinary team of patients and families, primary care physicians, specialists, subspecialists, hospitals, and healthcare facilities, public health and the community. Our national, state, and family partners make our community-based system of services possible for all children and youth in the medical home.

National Partners

American Academy of Pediatrics (AAP) Twitter Facebook YouTube
The AAP is an organization of 60,000 pediatricians committed to the attainment of optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults. The AAP has a Web site with information for pediatricians, and resources for parents. The AAP are co-signers of the 2007 Joint Statement of Medical Home Principles PDF and have been leading the medical home movement for children since 1967. For information on medical home at the chapter level, connect with your state AAP Chapter. (There are 59 US and seven Canadian chapters.)

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Agency for Healthcare Research and Quality (AHRQ)
The mission of AHRQ is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. Information from AHRQ's research helps people make more informed decisions and improve the quality of health care services. AHRQ was formerly known as the Agency for Health Care Policy and Research.

  • AHRQ Patient Centered Medical Home Resource Center
    This site is aimed at providing objective, evidence-based information to policymakers and researchers on the PCMH. Key features of this site include searchable citations database for journal articles, reports, policy briefs, and position statements pertaining to the PCMH; a listing the top Web sites on the PCMH and the variety of content covered; and exclusive access to white papers and issue briefs on various aspects of the PCMH.

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American Academy of Family Physicians (AAFP)
The AAFP is the national association of family doctors. It is one of the largest national medical organizations, with more than 93,000 members in 50 states, DC, Puerto Rico, the Virgin Islands, and Guam. Their mission is to improve the health of patients, families, and communities by serving the needs of their members with professionalism and creativity. They are co-signers of the 2007 Joint Statement of Medical Home Principles PDF and are part of the adult movement for medical home.

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American College of Medical Genetics (ACMG)
The ACMG provides education, resources, and a voice for the medical genetics profession. They make genetic services available to and improve the health of the public. The ACMG promotes the development and implementation of methods to diagnose, treat, and prevent genetic diseases. The American Academy of Pediatrics National Center for Medical Home Implementation and the American College of Medical Genetics’ National Coordinating Center for the Regional Genetics and Newborn Screening Service Collaboratives (NCC) in partnership with the ACMG and MCHB recently developed a pilot visiting professorship program. This program focuses on the specific topic areas of genetics and medical home and also establishing linkages between Regional Genetics and Newborn Screening Services Collaboratives (RCs) and AAP Chapters.

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American College of Physicians (ACP)
ACP is a national organization of internists — physicians who specialize in the prevention, detection, and treatment of illnesses in adults. ACP's membership of 126,000 includes internists, internal medicine subspecialists, and medical students, residents, and fellows. They are co-signers of the 2007 Joint Statement of Medical Home Principles PDF and are part of the adult movement for medical home.

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American Osteopathic Association (AOA)
The AOA is a member association representing more than 64,000 osteopathic physicians (DOs). The AOA serves as the primary certifying body for DOs, and is the accrediting agency for all osteopathic medical colleges and health care facilities. The AOA's mission is to advance the philosophy and practice of osteopathic medicine by promoting excellence in education, research, and the delivery of quality, cost-effective healthcare within a distinct, unified profession. They are co-signers of the 2007 Joint Statement of Medical Home Principles PDF and are part of the adult movement for medical home.

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Association of Maternal Child Health Programs (AMCHP)
AMCHP is a national non-profit membership organization that acts as an important resource to states for women’s and children's health programs with the overall goal of protecting the health and well-being of low-income and underserved families. Members of AMCHP include state government; directors of maternal and child health programs; directors of programs for children with special health care needs; adolescent health coordinators and other public health leaders; academic; advocacy and community-based family health professionals; as well as families themselves. AMCHP works with other national and state health partners to link families and children to the resources in their communities.

  • Collaborative April 2010 Issue of AMCHP Pulse 
    The April 2010 issue of the AMCHP Pulse is a collaborative edition with the AAP and is themed around medical home. AAP and AMCHP have a long history of collaboration at the national level and that partnership is mirrored in the states among public health leaders, pediatricians, and families in Title V agencies and AAP state chapters. This issue highlights the shared commitment that AAP and AMCHP have to promoting child health and improving health systems that serve children and their families.

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Centers for Disease Control and Prevention (CDC)
The CDC collaborates with partners to accomplish its mission of creating expertise, information, and tools to help people and communities protect their health through health promotion, disease prevention, injury violence prevention, and disaster preparedness. The CDC is involved in a cooperative agreement with the Medical Home Surveillance Screening Program (MHSSP) and the AAP.

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Maternal and Child Health Bureau (MCHB)
The MCHB is charged with the responsibility of promoting our mothers' and children’s health. Its predecessor, the Children’s Bureau, was established in 1912, however in 1935 Congress enacted Title V of the Social Security Act, which authorized the Maternal and Child Health Services Programs. Today, the MCHB, as part of the Health Resources and Services Administration (HRSA), US Department of Health and Human Services (HHS), administers Title V. The MCHB mission is to provide national leadership and to work in partnership with states, communities, public-private partners, and families to strengthen the maternal and child health (MCH) infrastructure, assure the availability and use of medical homes, and build knowledge and human resources in order to assure continued improvement in the health, safety, and well-being of the maternal and child health population. The MCH population includes all America’s pregnant women, infants, children, adolescents, and their families—including women of reproductive age, fathers, and children with special health care needs.

MCHB/HRSA is involved in the cooperative agreement with the National Center for Medical Home Implementation and the AAP. The MCHB also fund several other National Centers that are charged with improving the health and well-being of all children, especially those with special health care needs, and their families. For additional information on these National Centers, visit the About Us—National Agenda: Healthy People 2020 page.

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National Alliance on Mental Illness (NAMI)
NAMI is dedicated to improving the lives of individuals and families affected by mental illness. NAMI's support and public education efforts are focused on educating America about mental illness, offering resources to those in need, and insisting that mental illness become a high national priority. NAMI offers an array of peer education and training programs, initiatives and services for individuals, family members, health care providers, and the general public. NAMI's education and support programs provide relevant information, valuable insight, and the opportunity to engage in support networks.

  • StrengthofUs.org
    StrengthofUs.org is an online community where young adults living with mental health concerns can provide mutual support in navigating unique challenges and opportunities during the critical transition years from ages 18 to 25. Developed by young adults, the site is a user‑driven social networking community where members can connect with peers and share personal stories, creativity and helpful resources by writing and responding to blog entries, engaging in discussion groups and sharing videos, photos and other news.

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National Association of Pediatric Nurse Practitioners (NAPNAP)
NAPNAP has over 7,000 members and is the professional association for pediatric nurse practitioners (PNPs) and other advanced practice nurses who care for children. Their mission is to promote optimal health for children through leadership, practice, advocacy, education and research. NAPNAP has a member serve on the National Center for Medical Home Implementation’s Medical Home Project Advisory Committee.

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National Partnership for Women & Families
The National Partnership for Women & Families mission is to create a nation with equal pay and family-friendly workplaces. They believe that people have a right to information about the quality of their health care, and should have that information when they need to choose a doctor, hospital, or a health plan. They are a member of the Patient-Centered Primary Care Collaborative (PCPCC) and the National Center for Medical Home Implementation’s Medical Home Project Advisory Committee.

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Patient-Centered Primary Care Collaborative (PCPCC)
The AAP, along with major national employer groups, health plans, and other medical specialty societies, is a partner in the PCPCC. This coalition represents 50 million American workers and more than 300,000 physicians. The PCPCC believes that, if implemented, the patient centered medical home will improve the health of patients and the viability of the health care delivery system.

The PCPCC structures its efforts under five Centers that were created in part to operationalize the Joint Principles PDF. Each Center has a stated mission and has established a set of goals to continue to advance medical home. Center activities and workgroups are largely voluntary efforts, and all Centers welcome additional members, particularly those representing the consumer perspective:

  • Center for Consumer Engagement
    Engage the consumer in awareness activities through three ways: day-to-day operations, messaging and pilots. The center will continue the use of patient-centered medical home by focusing on how the concept and its components are communicated to the public and partner with large consumer groups to capitalize on their visibility and existing efforts.
  • Center for Employer Engagement
    Create standards and buying criteria to serve as a guide and tool for large and small employers/purchasers in order to build the market demand for adoption of the patient-centered medical home model.
  • Center for eHealth Information Adoption and Exchange
    Evaluate use and application of information technology to support and enable the development and broad adoption of information technology in private practice and among community practitioners.
  • Center for Multi-Stakeholder Demonstration
    Identify community-based sites to test and evaluate the patient-centered medical home concept; share information and best practices about pilots within a collaborative community; and serve as the connector to technical, quality improvement and education resources to facilitate ongoing demonstrations.
  • Center to Promote Public Payer Implementation
    Assist public payers as they implement and refine programs to embed the patient-centered medical home model by offering technical assistance, sharing best practices and giving guidance on the development of successful funding models.

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State Partners

Early Hearing Detection and Intervention Network (EHDI)
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. The National Center for Hearing Assessment & Management (NCHAM) is the administrator of the National Resource Center for Early Hearing Detection and Intervention.

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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 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. One of the goals of the National Center of Medical Home Implementation is to enhance communication between primary health care professionals and early intervention programs.

A child's primary healthcare professional's ability to perform continuous surveillance and structured screening within the context of a routine, well-child care visit provides an opportunity to identify special health care needs. However, once a child is identified with having a special health care need, appropriate diagnosis and follow-up must readily occur. It is in this "next step" that the relationship between the medical home and an early intervention program becomes critical as research has indicated that care for CSHCN is often fragmented and includes a mixture of duplication and gaps.

National Early Childhood Technical Assistance Center supports the national implementation of the early childhood provisions of the IDEA.

Part B of IDEA
Special Education for ages 3-5 Coordinators: This program provides free appropriate public education (FAPE) for children, ages 3 through 5 years, with disabilities.

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Interagency Coordinating Council (ICC)
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 a statewide system.

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Medicaid
Medicaid is a state administered program provided to certain low-income individuals, families, and children who fit into an eligibility group that is recognized by federal and state law. Each state sets its own guidelines regarding eligibility.

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Title V
Title V of the 1935 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, US Department of Health and Human Services. The result of Title V led to the establishment of state departments of health or public welfare in some states, and facilitated the efforts of existing agencies in others. Each state has a Title V Maternal and Child Health Contact and a Title V Children with Special Health Care Needs Contact.

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Family Partners

Family Voices (FV)
FV is a national grassroots organization that aims to achieve family-centered care for all children and youth with special health care needs and/or disabilities. Through their national network, they provide families with the tools to make informed decisions, advocate for improved public and private policies, build partnerships among professionals and families, and serve as a trusted resource on health care. FV has a chapter in each state with a contact, which can act as a resource to parents and families.

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Family to Family Health Information Centers (F2F HICs)
F2F HICs provide health care information to families that is family friendly and culturally sensitive, in order to help them make good health care decisions. They are run by experienced parents and supported by private and public funds. Family Voices has helped many of their volunteer network members, all of them parents, develop F2FHIC's around the country. By 2009, all states and the District of Columbia should have FOA funded F2F HICs.

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Genetic Alliance
Genetic Alliance is the world's leading nonprofit health advocacy organization committed to transforming health through genetics and promoting an environment of openness centered on the health of individuals, families, and communities. Genetic Alliance’s network includes more than 1,000 disease-specific advocacy organizations as well as thousands of universities, private companies, government agencies, and public policy organizations. The network is a dynamic and growing open space for shared resources, creative tools, and innovative programs.

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Institute for Patient- and Family-Centered Care
The Institute for Patient- and Family-Centered Care is a non-profit organization founded in 1992. The Institute takes pride in providing essential leadership to advance the understanding and practice of patient- and family-centered care. By promoting collaborative, empowering relationships among patients, families, and health care professionals, the Institute facilitates patient- and family-centered change in all settings where individuals and families receive care and support.

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AAP Partners

Bright Futures
The AAP works in the Bright Futures initiative in a federal partnership with MCHB. This is a national health promotion and disease prevention initiative that addresses children's health needs in the context of family and community. In addition to use in pediatric practice, many states implement Bright Futures principles, guidelines, and tools to strengthen the connections between state and local programs, pediatric primary care, families, and local communities. Whether you are a health care or public health professional, a parent, or a child advocate, Bright Futures offers many different resources for your use in improving and maintaining the health of all children and adolescents.

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Child Health Informatics Center (CHIC)
To meet the need for supporting Health Information Technology (HIT), the AAP launched the CHIC. The CHIC has focused its efforts on positioning itself as the “home” for HIT initiatives and demonstrates the AAP's commitment to ensuring that pediatrics is considered in national discussions about HIT, that members are provided with timely information and guidance during this time of rapid change, and most importantly, that children have access to high quality care.

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Committee on Child Health Financing (COCHF)
COCHF monitors and makes policy recommendations to the AAP Board of Directors on various aspects and sources for financing health care for children. The Committee also develops resources on managed care for pediatricians. COCHF collaborates with other Committees on informing chapters of federal and state financing activities to assist chapters in their efforts to influence the monies involved in state determination of Medicaid, MCH, and other government health care financing programs.

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Council on Foster Care, Adoption, & Kinship Care
The Council on Foster Care, Adoption, & Kinship Care is dedicated to improving the health and well being of children and youth in foster care, kinship care, and those who have been adopted.

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Council on School Health (COSH)
COSH is primarily for clinicians with an interest in school health, whether as a practicing clinician involved in the intersection of health and education or as a school consultant responsible for school or district school health issues. COSH addresses topics such as drug testing in schools, school food programs, preventing and treating homesickness, mental health, confidentiality issues, and sexuality education.

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Division of Community-based Initiatives (DOCBI)
The DOCBI promotes and supports pediatrician involvement in community-based child health initiatives. Their division staff manages three national grant programs: Community Access to Child Health Program, the Healthy Tomorrows Partnership for Children Program, and the Community Pediatrics Training Initiative. The division also houses the Council on Community Pediatrics.

  • Community Access to Child Health (CATCH)
    CATCH supports pediatricians who work with communities to ensure that children have increased access to Medical Homes and to any other needed health care services through training, technical assistance, peer support, networking, and funding opportunities.
  • Community Pediatrics Training Initiative (CPTI)
    CPTI is designed to collaborate with academic pediatric training programs working to develop educational curricula and scholarly efforts concerning community-oriented & community-based health care. Through this Initiative's interdisciplinary collaborations and community partnerships, pediatric academia and residents will be equipped with the tools and knowledge they need to become future professionals committed to improving children's health in their community.
  • Council on Community Pediatrics (COCP)
    The COCP provides a forum for networking and education for pediatricians and other health care professionals with an interest in community pediatrics. The COCP also has special interest groups that focus efforts on strategic planning and educational program development addressing early education and child care, Native American health, prevention and public health, community pediatrics education and training, and rural health.
  • Healthy Tomorrows Partnership for Children Program
    Healthy Tomorrows aims to improve the health status of mothers, infants, children, and adolescents by increasing their access to a medical home. Healthy Tomorrows projects address four key areas: access to a medical home, community-based health care, preventative healthcare, and service coordination. All projects target low-income populations.

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International Child Health Network (ICHN)
ICHN is a free and open service designed to establish connections that foster cooperation on a variety of health projects. This includes relief and development work, humanitarian service, equipment/supply donation, education, research, fundraising, and visitor exchange. The site is managed by the American Academy of Pediatrics’ Section on International Child Health.

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Practice Management Online (PMO)
PMO is the home for the best pediatric practice management information, tools, and resources for pediatricians and their office staff in one easily accessible Web site.

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Section on Administration and Practice Management (SOAPM)
The vision of the SOAPM is that all members of the Academy have the opportunity to attain and sustain professional fulfillment in administration and practice management. Through the recognition of best practices, educational opportunities, and the establishment of an open forum for discussion and dissemination of practical, effective strategies, SOAPM will enable its membership to improve practice management in pediatrics.

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Section on Developmental Behavioral Pediatrics
The objectives of the Section on Developmental & Behavioral Pediatrics are to improve the care of infants, children, and adolescents by providing an educational forum for the discussion of problems and treatments related to growth and development, stimulating research in, and the teaching of; developmental and behavioral pediatrics; and disseminating knowledge of pediatric growth and development through Academy channels to the medical profession at large.

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Section on Early Education and Child Care (SOEECC)
The SOEECC provides a forum for pediatricians and others interested in promoting the optimal development, health, and safety of children in child care.

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Section on Hospice and Palliative Care (SOHPM)
The mission of the PSOHPM is to ensure that all children requiring hospice and palliative care needs and their families have access to and receive the highest possible quality of careregardless of where they live.

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