 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).
Click on a topic below to learn more about what's
going on in Pennsylvania
Click here for Funding Opportunities in Pennsylvania
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
Contact:
Name: Molly
Gatto - Project Coordinator, EPIC Integrated Care PA Chapter,
AAP
Contact: Phone: 484-446-3000 | Email:
mgatto@paaap.org
Educating Practices in
Community Integrated Care (EPIC IC) 
Educating Practices in Community Integrated Care (EPIC IC) is a medical home development project funded by the Pennsylvania Department of Health and the federal Maternal Child Health Bureau. The EPIC IC Medical Home Program is funded by the Pennsylvania Department of Health, Bureau of Family Health
(state Title V agency). The grant administration and oversight is housed within the Division of Community
Systems Development and Outreach.
The EPIC IC medical home project is based on the Educating Physicians In their Communities (EPIC) model. EPIC IC is a statewide provider of education/quality improvement programs using office-based change as the key to improving the care provided to children and youth with special health care needs (CYSHCN).
The EPIC IC project facilitates the provision of medical homes to CYSCHN throughout the Commonwealth of Pennsylvania. Similar to other quality improvement projects, EPIC IC uses many tools to measure and monitor strengths, weaknesses, and outcomes of the project. This includes but is not limited to:
- Patient registries
- Tracking of care coordination
- Medical Home Index
- Family survey
- Quality improvement cycles
- Assessment of transition efforts
Participating in the Program
Practices work with EPIC IC to meet many care coordination criteria. The criteria include:
- Identification of practice team members
- Recruitment of Parent Partners to work with the practice team
- Development of a process for creating a comprehensive and continuously-updated patient registry of CYSHCN
- Submission of a brief monthly report
- Collaboration with local, community-based organizations
- Participation in EPIC IC monthly conference calls
- Attendance at EPIC IC conferences.
After meeting the above criteria, EPIC IC works with practices to refine their model of care delivery so that successive quality measures are incorporated. 62 practices have been trained by EPIC IC, over 30% of which are currently participating in intensive quality improvement activities with the EPIC IC program. EPIC IC practices represent:
- all 6 regions of PA
- 29 counties
- Urban, rural, suburban areas
- Multiple ethnic and racial groups
- Federally qualified health centers
- Three major children’s hospital systems
- All sizes of practice…with populations varying from as little as 1500 to as many as 30,000 patients.
For more information:
Please visit www.pamedicalhome.org or contact:
Renee Turchi, MD, MPH
Renee.Turchi@drexelmed.edu
Molly Gatto
mgatto@paaap.org
Presentations
EPIC Overview | EPIC
Family-Centered Care
| EPIC Care
Coordination
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: Abstract
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.
Educating Medical Professionals
in the Community (EMPC):
Creating Medical Homes for Young Adults with Special Healthcare
Needs
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 - (See
Project Description)
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 Demonstration Project Sites Fact
Sheet 
Contact Info:
Stephanie DeMuro, Medical Home Coordinator: sdemuro@pafp.com or 1-800-648-5623.
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 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.
MCH Contact:
Melita J. Jordan, CNM, MSN, APRN C
Director, Bureau of Fanily Health
Address: PA Department of Health, 7th & Forster Streets
Harrisburg, PA 17120
Phone: 717-787-7192 Fax: 717-772-0323
Email: mejordan@state.pa.us
Internet site: www.health.state.pa.us
CSHCN Contact:
Michelle Connors
Director, Div of Community Systems Development & Outreach
Address: PA Department of Health, 7th & Forster Streets
Harrisburg, PA 17120
Phone: 717-772-2763 Fax: 717-772-0323 f
Email: mconnors@state.pa.us
Internet site: www.health.state.pa.us
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:
Microsoft Word
The Child Advocacy Project of Philadelphia: www.capp4kids.org
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.
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.
AAP Chapter Educating Physicians In Community
Integrated Care (EPIC)/Medical Home Program: www.paaap.org/mod.php?mod=userpage&menu=807&page_id=14
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.
Click
here for additional information on the D-PIP.
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
Autism Task Force Final Report
This Task Force, which is comprised of over 250 family members
of people living with autism, service providers, educators,
administrators and researchers, was charged with developing
a plan for a new system for individuals living with autism
and their families that would make Pennsylvania a national
model of excellence in autism service delivery.
http://www.dpw.state.pa.us/General/AboutDPW/SecretaryPublicWelfare/AutismTaskForce/003671610.htm
Funding Opportunities
Deadline: September 5, 2006
The GlaxoSmithKline Tenth Annual IMPACT Awards are designed to reward excellence in the delivery of nonprofit community healthcare. GlaxoSmithKline will award a total of up to $400,000 to small and mid-size community-based healthcare organizations in the Greater Philadelphia area.
Up to ten award winners will receive $40,000 each and will be honored at a ceremony in Philadelphia in 2007.
The awards are designed to recognize success and achievements for existing overall work. This award is not a grant or a contract and may be used at the discretion of the recipient organization for any program except debt reduction. The organization need not present a new project. The IMPACT Awards are given to organizations and not specific programs.
Applicant organizations must be a 501(c)(3) nonprofit organizations with total annual budgets under $2 million and be located in Berks, Bucks, Chester, Delaware, Lancaster, Montgomery, or Philadelphia counties. Applicant must have health and health-related issues as its primary focus and mission (not human services).
Visit the award program's Web page for complete eligibility information and application procedures.
RFP Link:
http://fconline.foundationcenter.org/pnd/10003579/gsk
For additional RFPs in Health, visit:
http://foundationcenter.org/pnd/rfp/cat_health.jhtml
State Resources on the Internet
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.
Last Updated
August 27, 2008
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