Medical Homes in Massachusetts
 This page is designed to keep you informed about events and activities happening in Massachusetts 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.

Massachusetts Medical Home Team Contact:

Name: Connie Carroll, Director of Care Coordination and Medical Home Initiatives
Contact: Email: connie.carroll@state.ma.us   
State Team Roster available at: www.medicalhomeinfo.org/model/downloads/State Teams/Massachusetts Medical Home Team.doc

The Commonwealth of Massachusetts has been awarded an MCHB State Implementation Grant for Integrated Community Systems of Services for CSHCN
Contact Person: Nicole Roos, MBA. nicole.roos@state.ma.us
Goals and Objectives:
Goal 1: Build system capacity for family-professional partnerships statewide
Goal 2: Enhance medical provider capacity for providing medical homes for CYSHCN
Goal 3: Assure children receive early and continuous screening and referral to appropriate services
Goal 4: Build system capacity for ensuring YSHCN receive services necessary to make successful transitions to adult life
Goal 5: Strengthen collaboration of youth, families, providers, and state agencies in enhancing systems of care for CYSHCN
Goals 6: Enhance advocacy skills of youth and families

Massachusetts Statewide Medical Home Implementation Plan - Promise to the State (www.medicalhomeinfo.org/grant/states/MASSAC~1.PDF)
The MA Medical Home Initiatives Steering Committee (comprised of families, MCAAP, Consortium for CSHCN, Title V/DPH, AAP CATCH, and the MA Chapter of Family Physicians) have written a plan outlining specific goals for the state to achieve a system of care in which all CSHCN have access to a medical home by 2010.

MCHB Medical Home Grant "The Massachusetts Medical Home Project"
(www.medicalhomeinfo.org/grant/states/MCHB Grants/MassMCHBGrant.pdf)
A medical home development project funded by the MCHB which partners care coordinators from the Dept of Public Health with primary care pediatricians in the community.

    Documents available to view on the Massachusetts medical home state page:
  • "2003 Request for Response from Primary Care Practitioners:" used to identify primary care pediatrics practices around the state; from the respondents, Title V/DPH selected the sites place care coordinators.
  • Six Month Report for the Massachusetts Medical Home Mentoring Project-August 2002
  • Medical Home Status for Children with Special Health Care Needs in Massachusetts:
    Background Brief and Executive Summary
  • Care Coordination Program for CSHCN: A Resource for Parents and Providers Brochure
  • Programa de Coordinación de servicios para niños con necidades especiales médicas: Un recurso para padres y proveedores Brochure

Healthy Tomorrows Partnership for Children Grants 2002-2007

The Worcester Medical Home Initiative
Purpose: The goal of the project is to improve health outcomes by creating medical homes for children with special health care needs attending the 2 pediatric and 1 family practice office sites. We will use evaluation tools to measure the organization and delivery of primary care services in supporting chronic condition management, care coordination, community outreach, data management, and quality improvement. Simultaneously, families will participate in an evaluation to measure emotional, physical, social, health, and developmental progress as well as consumer satisfaction. For more information on this project go to: www.medicalhomeinfo.org/states/state /Downloads/MA%20Info/Boston%202002.doc

Advocating Success For Kids (ASK)
Children's Hospital, Boston, MA
Children's academic success during preschool and primary grades may be compromised by developmental concerns caused or exacerbated by psychosocial stressors such as substandard housing, complex family situations, substance use, and domestic violence. In partnership with the Boston Public Schools and 6 community-based urban primary care sites, the Advocating Success for Kids (ASK) program will provide diagnostic consultations and follow-up visits for children presenting with behavioral, developmental, or learning difficulties that impair their ability to learn effectively in their classrooms. A multidisciplinary ASK team, consisting of a psychologist, educator, developmental pediatrician, and case manager, will meet with families at their community health center and provide case coordination-linking families with indicated educational, medical, and psychosocial support services.

Goals of the ASK program are to work with families, primary care providers, and the local school system to: improve school readiness and performance of children ages 3 to 9 years; and improve the emotional well-being of children served through the ASK program.

For more information on the Healthy Tomorrows Grant Program go to: www.aap.org/commpeds/htpcp/index.html
For more information on any of these HTPCP projects, please e-mail your name, address, telephone, and fax numbers with your specific request to healthyt@aap.org.

Medical Home Materials

  • Medical Home Brochure for Families
    A NEW WAY…A BETTER WAY. THE MEDICAL HOME PARTNERSHIP: Building a Home Base for Your Child with Special Health Care Needs
  • Medical Home Brochure for Providers
    SMALL STEPS…BIG DIFFERENCES. THE MEDICAL HOME PARTNERSHIP: Practical Tips for Physicians Caring for Children with Special Health Care Needs
  • Care Coordination Program for CSHCN: A Resource for Parents and Providers
  • Programa de Coordinación de servicios para niños con necidades especiales médicas: Un recurso para padres y proveedores

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.

Healthy Tomorrows Partnership for Children Grants
Family Advocates of Central Massachusetts
Providing a Medical Home for children of low-income families includes the capacity to address the legal issues that affect the health of children and families. Family Advocates of Central Massachusetts will incorporate attorneys from LACCM as full members of the multidisciplinary teams caring for children from low-income families in four practices located in Worcester, Webster, Milford and Fitchburg Massachusetts. The attorneys will work closely with health care providers to develop a system of care that integrates legal advice and representation as an additional tool to address the social issues within families that adversely affect the health of children. The attorneys will develop screening protocols and staff trainings that fit within the organizational culture of the four medical practices. Each year, they will provide counsel and advice to more than 100 low-income families with children, and will provide full representation to more than 30 low-income families with children, at the four practice sites in Central Massachusetts.

Projects Goals & Objectives: The goals of this project are: 1) To improve housing stability, 2) To improve financial security, 3) To improve dignity and safety, and 4) To improve access to health care.

For more information on the Healthy Tomorrows Grant Program go to: www.aap.org/commpeds/htpcp/index.html
For more information on any of these HTPCP projects, please e-mail your name, address, telephone, and fax numbers with your specific request to healthyt@aap.org.

Genetics Grant
Project period: 3 years from 6/1/2001 to 5/31/2004
The goals of the project are to: 1) Assure access to care coordination and timely referral to services for CSHCN (particularly children identified through newborn hearing screening, newborn metabolic screening, and FIRSTLink electronic screening of birth certificates to identify newborns at risk) and through genetics diagnostic centers; 2) Establish an integrated child health data system across Department of Public Health (DPH) programs with links to the medical homes of CSHCN and with personal access for families served by participant programs; and 3) Increase community and program staff genetics knowledge and capacity, as outlined in the state Genetics Strategic Plan.

Hemophilia Grant
Project Period: 1 Year From: 6/01/01 to 5/31/02
The goal of the region I core hemophilia program is to provide culturally sensitive, family centered, comprehensive care services to individuals with hemophilia and other coagulopathies.

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.mcaap.org/

American Academy of Family Physicians (AAFP) Chapter: www.massafp.org/

Title V CSHCN Program - "The Division for Special Health Needs" www.mass.gov/dph/fch/dshn.htm

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: Janet M. Farrell
Contact: Phone: 617-624-5957 | Fax: 617-624-5990
E-mail: janet.farrell@state.ma.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: Ron Benham, Part C Coordinator and Director of EI
Contact: Phone: (617) 624-5962 | Fax: (617) 624-5990 | AltPhone1: (617) 624-5070
Email: ron.benham@state.ma.us
Website: www.mass.gov/dph/fch/ei.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: Russell Hoyt, 619 Coordinator
Contact: (781) 338-6360 (Hoyt) | Fax: (781) 338-3370 | Email: rhoyt@doe.mass.edu

Name: Elisabeth Schaefer, Administrator
Contact: Phone: (781) 338-6357 (Schaefer) | Fax: (781) 338-3380
Email: eschaefer@doe.mass.edu

Website: www.doe.mass.edu/els/

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: Barbara Prindle Eaton, ICC Chair
Contact: Phone: (508) 775-6240 | Fax: (508) 790-4774 | Email: bpeaton@cccdp.org

Resources/Documents
Practicing Comprehensive Care: A Physician's Operations Manual for Implementing a Medical Home for CSHCN - created by the Pediatric Alliance for Coordinated Care, the manual offers practical advice and suggestions to support the day-to-day operations of pediatric offices to more efficiently and effectively serve children with special health care needs. archives.communityinclusion.org/publications/compcare.html

Transition Planning for Adolescents with Special Health Care Needs and Disabilities: A Guide for Health Care Providers (2000) - The guide gives information, resources and strategies needed by providers to support adolescents and their families to meet the challenges of transition. archives.communityinclusion.org/transition/providerguide.html

Transition Planning for Adolescents with Special Health Care Needs and Disabilities: Information for Families and Teens (2000) - This booklet has been developed for families to help you prepare with your teen for his/her adulthood. archives.communityinclusion.org/transition/familyguide.html

Partnerships For Quality - Transcripts and resources from this conference held by Ma Family Voices that brought together families and health professionals to discuss how to improve care for CSHCN. www.massfamilyvoices.org/pfq/speakers.html

State Waiver Information: www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/08_WavMap.asp
Waivers are the result of a process that allows state Medicaid agencies to apply for and receive permission from HCFA to provide services not otherwise covered by Medicaid and/or to do so in ways not described by the Social Security Act. Most Medicaid managed care programs require Waivers. The Waivers, which can differ greatly, are known by their numbers (1115, 1119), or as home-and community-based, or as Katie Beckett Waivers.

Educational Initiatives
This section provides information on training initiatives on the medical home. Some states will discuss their outreach projects in relation to physicians, families, and the community.

The Medical Home Network Project: www.neserve.org/neserve/wwd_med_hm.html
This educational program of New England SERVE brings together primary care providers, parents and community partners to demystify the theory and practice of the Medical Home. Its case-based curriculum offers knowledge, awareness, and strategies for implementing small practice improvements. This project is ongoing.

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

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
Family Voices: www.massfamilyvoices.org/
Partnering with professionals and families to advocate for health care services that are family-centered, community-based, comprehensive, coordinated and culturally competent. Materials developed by Massachusetts Family Voices.

Massachusetts Family-to-Family Health Care Information & Education Center www.massfamilyvoices.org/F2FHIC.html
Activities include providing training opportunities and technical assistance to families to help them advocate for quality health care services for their children and youth with special health care needs.

  • Provides public benefits information to families of children and youth with special health needs, and others,
  • Helps families navigate various health care systems and supports to ensure their children can live at home,
  • Creates and/or shares opportunities for parents and professionals to work together to ensure children and youth with special health care needs are active participants in their communities, and
  • Helps families have an active “voice” in the decision making process about their services and supports,
  • Mentors other parents to work in different regions of the state to become resources for families just beginning the process of navigating these complex health benefit’s systems,
  • Provides opportunities for families to participate in topical conference calls,
  • Hosts a statewide listserv where families and professionals can build partnerships, share information and resources and support each other in our advocacy efforts on behalf of children and youth with special health care needs.

Leave a message at 1-800-331-0688, ext. 210. Your call will be returned. Or e-mail: massfv@fcsn.org

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!

Island Parents Educational Support & Training Center (IPEST): www.ipest.org/
Trains parents and other caregivers to become active participants in the educational process of their child/children with a disability. The ultimate goal is to pass these skills on so that children can advocate for their own educational needs. They work with families whose children range in ages from birth to 22 years.

NAMI of Massachusetts (National Voice of Mental Illness): namimass.org/
Education, advocacy and support for persons with brain disorders (mental illnesses) and their families.

PACCTips: archives.communityinclusion.org/pacctips/
PACCTips is a place for families to browse to learn about approaches, equipment, supplies that have worked for other families as they care for their child with special health care needs or disability.

Resource Guides:

  • Family TIES Resource Directory www.massfamilyties.org/directory.html
    This directory was developed by the Family TIES Project to help parents and providers locate available services and resources for children and youths with special needs.
  • Western Massachusetts Resource Guide www.medicalhomeinfo.org/states/state /massachusetts.html
    This guide was developed for the Every Child Deserves a Medical Home training program on November 8, 2003.
  • The Association for Retarded Citizen (Arc) Family Resource Guide www.thearc.org/familyguide/massachusetts.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.

Early Hearing Detection & Intervention (EHDI) Information for Parents:
Description of EHDI Program | Babies Diagnosed with Hearing Loss
www.medicalhomeinfo.org/screening/State/massachusetts.html

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 /massachusetts.html

Last Updated April 30, 2007