1. Building Your Child’s Medical Team through a Medical Home
Sherry Santa
Laura J. Warren
Texas Parent to Parent

2. What is a Medical Home?
An approach to providing comprehensive medical care
Not a building, house, hospital or home healthcare service
Care team works in partnership with a child and a child’s family to assure that all of the medical and non-medical needs of the patient are met
National Center for Medical Home Implementation
It is an approach to providing comprehensive primary care where the medical team works in partnership with a child and their family to assure that all of the medical and non-medical needs are met. The medical team can help the family and child access, coordinate and understand services that are important to the overall health of the child.

3. Care within a Medical Home should be:
Accessible – not just the doors or ramps but hours, payment methods, and responsive to phone calls or s
Family-centered – recognizes parents as the core source of information on the child and builds a team that includes the parent
Continuous – same team of doctors for infancy through transition to adult care

4. Care within a MH should be (continued)
Comprehensive –addresses both acute and long-term care
Compassionate – helps families access community- based support and resources
Culturally effective – includes translation and interpreters but also a knowledge of a family’s culture, beliefs, etc.
Coordinated- create a family care plan with the family to share with other professionals involved in the child’s care

5. Roles of a Medical Home Respects your child and your family
Shares information with you and includes you in decisions
Provides health care
Works to catch problems early
Medical Home Leadership Network, University of WA 2012

6. Roles of a Medical Home
Helps you plan for & manage chronic health problems
Finds specialists and has recommendations for you
Connects you to community resources
Lowers family stress
Medical Home Leadership Network, University of WA 2012

7. Who is Part of a Medical Home?
You, your child, your family
Doctors, nurses, dentists, therapists, pharmacists, other care professionals
Teachers, social workers, personal care providers, community organizations
Other service providers that may offer assistance
Other family, friends, neighbors

8. Roles of Parents/Caregivers
You are a constant in your child’s life
You are an expert in the strengths and needs of your child
You are the supervisor of your child’s medical home
You are a visionary who sees the “big picture” of your child and his/her future

9. Assess Your Medical Home - Does it:
Treat you as a central & equal member of the medical home team
Share mutual respect and trust with you and your child’s doctor
Respect your culture and religious beliefs are valued
Partner with one another to meet your child’s needs
Medical Home Leadership Network, University of WA 2008

10. Assess Your Medical Home – Does it:
Ensure that your child receives adequate care
Help you find other providers and services
Make you feel supported
Make sure you understand your choices
Medical Home Leadership Network, University of WA 2008

11. Ensuring Good Care in a Medical Home
Know everyone on your medical home team
Ask questions at each visit
Ask for more time for your visit if needed
Talk about important changes
Make a care notebook and share it with your medical home team
Medical Home Leadership Network, University of WA 2008

12. Ensuring Good Care in a Medical Home
Ask for clarification if you don’t understand
Ask for a written list of expectations until your child’s next visit
Ask about after-hours care if needed
Medical Home Leadership Network, University of WA 2008

13. How to talk with your Child’s Doctor to Start a Medical Home
Important starting points
Your doctor likely has had little formal training in how to provide a medical home
Most doctors, like most professionals, welcome constructive feedback

14. “I have a concern” – Set the stage
Ask yourself: What works for me in the practice? What does not work?
Ask for a 30 minute office visit, if possible

15. “I have a concern” – Set the stage
Frame the discussion as collaborative:
Feedback sandwich: I really appreciate xxx about the way you care for my child. I need more help with xxx. You & your staff are great champions for my child, & I’m excited to work better together.
Get buy-in: Is it ok if we talk about ways to work better together?

16. Help with access to care
Ongoing relationship with team
Do you have a first contact? (Back line, direct line to nurse or care coordinator)
How does the practice set their schedule, and how can you see the same provider(s) when you visit?

17. Help with access to care
Care is integrated across settings
Does your practice know what is going on with your specialists, school, home health, community services?

19. What do you expect the practice to know?
Tips:
Provide oral update at beginning of each visit (or bring written summary)

20. Help with Access to Care (Continued)
Tips (continued)
Ask your specialist, school, coordinator to write a summary to share with your medical home
Best practice for urgent issue is handoff and closed-loop communication. To facilitate, check in (“I let Dr. Specialist know that Dr. Primary was going to call. Do you know if they had a chance to talk?”)

21. Help with family-professional partnerships
Families participate in decision-making and give feedback
Does the practice survey families about their experience?

22. Help with family-professional partnerships
Tips:
If you get a survey, fill it out! Especially write in comments
Write a letter thanking the practice when they have done a good job. Be SPECIFIC
Sets the stage to be receptive to feedback when you really need a change
Sample family survey Pediatric-Medical-Home-Family-Index- Survey_2005.pdf

23. Help with care coordination
Are you getting care coordination?
Are you regularly assessed for care needs?
Does someone help you track referrals or test results?
Do you need a team meeting?

24. Help with care coordination
Tips:
Ask for a care coordinator (medical home, insurance plan, community resources). If you don’t know, ask other parents where they get their coordination html
Ask for the doctor you have the best relationship with to schedule a team meeting. Bring someone to take notes

25. Help with care coordination
Proactive plan of care
Assess: Do you have a written portable medical summary, emergency action plan, or plan of care?

26. Help with care coordination
Tips:
Download a template and try to fill it out before asking your medical home to add to it
Emergency Action Plan template
Update your care plan at least every 6 months, or after a major change or hospitalization. Save all your summaries or notes in one folder to stay organized

27. Medical Home Checklist
Your child’s pediatrician or family physician may not have all of the following pieces of Medical Home in their practice, but it will help to know what to ask for and what you can work on together. You can use this list when choosing a new physician for your child, or as a way to start a conversation with your child’s doctor about Medical home.
Adapted from A NEW WAY…A BETTER WAY. The Medical Home
Partnership: Building a Home Base for Your Child with Special Health
Care Needs: New England SERVE

28. Your child’s primary care doctor and their office is accessible.
Available after hours, on weekends and holidays
Accepts your child’s health insurance
Office and equipment physically accessible to your child

29. Staff within your child’s primary care office know you
and help you 
Knows you and your child when you call
Recognizes and accommodates your child’s special needs
Responds to requests for prior approvals, letters of medical necessity for your child’s insurance or documentation for other programs and services
Provides written materials in a language you understand

30. Your child’s primary care doctor and office staff help you to coordinate your child’s care
Follows up with difficult referrals
Helps you to find needed services such as transportation, durable medical equipment, home care and ways to pay for them
Explains your child’s needs to other health professionals

31. Your child’s primary care doctor and office staff help you to coordinate your child’s care
Reaches out to your child’s school or day care providers to help them understand your child’s medical condition
Encourages and supports frequent communication between all persons involved in your child’s care (with your consent)
Organizes and attends team meetings about your child’s plan of care that includes you and other providers

32. Your child’s primary care doctor and office staff work with you to plan your child’s care
Helps you set short-term (3-6 months) and long- term (the next year) goals for your child
Gives you important information, such as recommendations or new treatments, in writing
Works with you to create and update a written plan of care for your child’s medical and non- medical needs

33. Your child’s primary care doctor and office staff support you as a caregiver
Helps you connect with family support organizations and other parents in your community
Provides information on community resources
Finds and shares new information, research or materials that are helpful in caring for your child

34. Your child’s primary care doctor and office staff support you as a caregiver
Helps you to advocate on behalf of your child
Plans for adult health care services (if appropriate for your child’s age)

35. Mental Health (English)
How other families have dealt with mental illness.
Watch the Video: Medical Home (English)
Medical Home

36. Resources for Medical Home

37. National Center for Medical Home Implementation https://medicalhomeinfo.aap.org/Pages/default.aspx
TxP2P Medical Home Toolkit
American Academy of Pediatrics
Medical Home Portal

38. Thank You! Sherry Santa Medical Education Program
& Texas F2F Coordinator
Laura J. Warren
Executive Director
Texas Parent to Parent