| Practice
Based Quality Improvement Mentors
Projects working with primary care physicians
using a continuous quality improvement model to create medical
homes in the community.
Core qualities of these mentors are: the
provision of training to other practices and/or the community;
engaging practices in a quality improvement process; and
developing and disseminating resources and tools. Most practice
mentor activities are funded through MCHB Medical Home Implementation
Grants.
Models:
The National Medical Home Learning Collaborative Strategy
The Medical Home Learning Collaboratives operated over a 15-month period. Title V agencies and primary child health care offices worked together with faculty from the National Center for Medical Home Initiatives at the American Academy of Pediatrics, the Center for Medical Home Improvement, and NICHQ with support from the US Maternal and Child Health Bureau to improve care for CYSHCN and their families.
Teams from participating primary care organizations achieved dramatic results by the application of effective quality improvement methods (the Model for Improvement and methods for spread of innovation). In addition, Title V agencies worked to develop the internal capacity to support teams as they learn and put into action improvements over the life of the Collaborative and beyond. As part of this process, Title V programs increased their understanding of community-based primary care practice and statewide primary care professional organizations.
Vitally important to the success of this Collaborative model is the concept of “spread,” the dissemination of innovation. The Collaboratives devoted substantial time, energy, and learning to strategies for Title V agencies, in conjunction with state-level pediatric and family practice professional organizations and family advocacy groups, to successfully expand breakthroughs and improvement to primary child health care practices.
The following tools and resources can assist you in implementing this model:
- A Guide to Assisting Practices to Implement Medical Home - (Appendix B of the Final NICHQ MHLC Report). Includes lessons learned from the National Medical Home Learning Collaborative. Includes a short list of high-leverage strategies to improvements, using tested tools to guide quality improvements, and tools and resources identified by the participants in the NICHQ Medical Home Learning Collaboratives I & II, and by faculty of the Center for Medical Home Improvements, and the National Center of Medical Home Initiatives for Children with Special Needs.
- Medical Home Spread Planner: Self-assessment tool and strategic guide for teams seeking to promote Medical Home model implementation on a statewide basis. From the 2005 NICHQ National Medical Home Learning Collaborative Final Report. Spread Planner
- Additional Tools and Forms are available by clicking here.
Center for Medical Home Improvement
(CMHI)
CMHI supports Medical Home (MH) implementation in primary
care settings through quality improvement and parent –
professional partnerships. A key component of the CMHI model
is the development of a core team within the primary care
setting that includes a lead physician, a care coordinator
and at least two Parent Partners. These core teams meet
bi-monthly to identify their improvement aims, develop and
implement improvements, measure outcomes and then continue
to make sequential improvements built on prior efforts.
A quality improvement team includes:
- A lead pediatrician/primary care provider
- A key non-MD office staff member/care coordinator parent
partners (at least 2)
- A commitment of time
- A quality improvement process
- Supportive facilitation/consultation
- Opportunities for collaborative learning
Family and professional partnerships form the overarching
theme of CMHI activities. The focus is upon strategies that
define the primary care role in the management of children
with special health care needs. CMHI works to assist practices
in establishing a new set of primary care behaviors to provide
Chronic Condition Management (CCM) to serve children and
families who use the health care system most often and expand
services to include:
- Care coordination
- Information Exchange
- Family Education and Advocacy
CMHI is currently working on a new project, Beyond
the Medical Home: Cultivating Communities of Support for
Children/Youth with Special Health Care Needs, to extend
previous efforts by improving transitions to adult services
and by establishing effective methods of communication and
coordination among families, community-based organizations
and the Medical Home. Two Medical Home practice networks,
one in Concord (NH) and one located within NH’s Seacoast
Region will address three critical needs: 1) expansion of
Medical Home access within practice networks; 2) creation
of transitions to adult services by inclusion of family
medicine practices with a QI focus on transition; and 3)
implementation of effective family and interagency coordination
and communication strategies. -
a project in partnership with the NH Bureau of Special Medical
Services (Title V), NH Family Voices, and the NH chapters
of the American Academies of Pediatrics and Family Physicians.
Additional CMHI resources and tools include:
- The Medical Home Improvement
Kit: a user-friendly resource for primary care
providers, their office staff, and the children and families
whom they serve. It will enable you to design family-centered
medical homes.
The kit offers:
- Provider/staff assessment tools (designed for busy
primary care practices)
- Parent assessment tools (to evaluate care from
the family perspective)
- A medical home quality improvement process that
works
- Practice enhancement tools, guides, resources and
suggestions (to assist
your family-centered medical home improvement process).
This kit will:
- Enable your practice’s “core team”
to implement an improvement
model to build and provide a primary care medical home
for children with
special health care needs (CSHCN) and their families.
- Guide you and the families whom your practice serves
to assess the
quality of the care and services provided; to develop
practice tools and
strategies for improving care and outcomes; and to measure
the impact of
practice improvements.
- Establish your practice as a center of primary care
excellence in the eyes
of consumers, colleagues, community members and payers.
- Medical Home Measurements
The
Medical Home Index, developed by CMHI, has set the
standard across the nation for measuring medical home
capacity in physician practices. Nearly all of the Medical
Home State Teams and MCHB Medical Home Grantees have adopted
the use of this tool in their projects.
- Medical Home Index - Measure the
baseline. Where is the practice on a continuum of
“Medical Homeness”?
- Family Index - What do the families
of children with special health care needs have to
say about their care and its quality?
For more information, go to: www.medicalhomeimprovement.org
Educating Physicians in Community
Integrated Care (EPIC IC)
is a collaborative effort of the Pennsylvania Department
of Health, Division of Special Health Care programs (DOH
Title V), family organizations (Family Voices, Parent to
Parent), and the PA Chapter of the AAP, funded by the MCHB
and the Pennsylvania Department of Health. EPIC IC Medical
Home project is based on the Educating Physicians In their
Communities (EPIC) model. EPIC IC is a statewide health
care professional education program using office based change
as the key to improving the care provided to CSHCN.
The mission of the program is to enhance the quality of
life for CSHCN through recognition and support of families
as the central caregivers for their child, effective community-based
coordination and communication, and improved primary health
care.
The EPIC IC Medical Home project was developed to 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.
The curriculum for the program is divided into 5
components:
Twenty-eight
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.
The first step for the EPIC IC practice teams was to do
a self evaluation of their practices using the Medical Home
Index. Each practice team has developed and started to implement
a quality improvement cycle based on needs identified by
the practice. These twenty-eight teams will also provide
in-office or grand rounds presentations based on the basic
elements of the medical home to physicians and office staff.
Pennsylvania AAP Chapter Web site:
EPIC/Medical
Home Program
EPIC IC Sample Forms: Microsoft Word 
Resources
Each year the National Center plans to
bring new teams that include individual practices, community
based initiatives, and statewide initiatives into the National
Medical Home Mentorship Network.
If you would like more information on this program or on
how to begin the process of developing a plan for your state,
please call 847/434-7621, or send e-mail to medical_home@aap.org.
August 7, 2008
Last Updated
August 7, 2008
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