Information for Providers

What is a medical home? Here is an example: John, a 14 year old with cystic fibrosis and his family have recently moved from California. Today is his first visit with his new primary care physician, Dr. Jones. In California, John received almost all of his health care from a pulmonary disease specialist. In Dr. Jones' waiting room, John was asked to complete a questionnaire for teenagers with chronic conditions. In addition, he was asked what he knew about his disorder, what he did to manage his disorder, how he was doing in school, in what outside activities he participated, and what medical and social concerns he had for the future. John's parents were also asked to complete a form that included questions about other providers and their role in John's care. A nurse, the office care coordinator, reviewed that information with the family and started a care plan that listed current concerns and goals for the future.

Next, the pediatrician examined John and reviewed the care plan with John and his family. The pediatrician made sure they had an appointment with the pulmonary specialist and also asked about how John, his siblings and parents were adjusting to the move. Did they have any unmet family needs. Finally, he shared information on web sites about cystic fibrosis and teenagers with special health needs. He also mentioned there was one other family in the practice who had a teenager with cystic fibrosis if John and his family would like to meet them. John's family was very impressed with this new approach to primary care for their son, and now see this office as their medical home rather than the pulmonary specialist.

The Medical Home is the centralized headquarters for health care where the needs of children and families are recognized, supported and integrated within a community approach (Cooley & McAllister, 2001). "Building a medical home" requires the commitment and leadership of physicians and partnerships with families. It involves consideration of the entire office including the clinical encounter, the office systems that support the encounter and the physical structure of the office. The focus of the Oregon Medical Home Project is to assist primary care practices in building medical homes by implementing a “chronic condition management” program and making the necessary changes in the office to support this program.

We have followed an approach to office systems change and chronic condition management developed by Carl Cooley, Jeannie McAllister and their co-workers at the Center for Medical Home Improvement. Important components of this model are; organizational capacity, chronic condition management, community outreach, data management and quality improvement (Medical Home Index, CHMI, 2001). Critical activities include forming partnerships with families, identifying and monitoring children with special health care needs (CSHNs), coordinating care in a systematic manner, improving communication with medical specialists and other community resources, and creating an office team that includes parents. Examples of practical tools to use in the office are presented on their website (Medical Home Tool Kit). These include:

• special needs information script for office receptionist (for scheduling)
• pre and post visit mini-screenings to obtain family feedback
• "Hot Tips for Busy Parents" (information sheet on scheduling office visits, phone calls, resources)
• "Today's Concerns" (form for youth and family)
• several examples of care plans

Ed Wagner and his colleagues in Improving Chronic Illness Care (ICIC) at the Group Health Cooperative in Washington have developed a model for primary care of adults with chronic illness (www.improvingchroniccare.org). The essential elements of this model are linkages to community resources, a health system that values chronic care, self-management support, delivery system redesign, decision support (e.g., use of practice guidelines) and clinical information systems (use of computer systems for registries, “reminders” and feedback to providers).

Both models emphasize the need to change from a reactive to a proactive health care system that emphasizes maintaining health.  They have in common a redesign of the office system that includes development of a practice team and identification of a care coordinator; building partnerships with individuals, families and community providers; creating information systems that support chronic care management; and use of office tools such as evidence-based care guidelines.   The ICIC model emphasizes self-management support and is developing support tools such as the Healthy Changes Plan.  The success of both models depends on improving the support from the health care system for quality chronic care, for example, by improving reimbursement or other compensation.

How do you get started?

The Oregon Medical Home Project has Resource Teams to help you get started. We have established 6 Resource Teams in 6 different communities in Oregon. Each team is composed of 2 parents of CSHN, a community health nurse and a pediatrician. In addition to assisting families and health care providers identify appropriate resources, our teams will work with you and your office staff to help you build your practice team as a first step.

Resources

Resource guide
Screening and surveillance
Identifying CSHN to enhance office management
Building partnerships with families
Care coordination
Care guidelines and care plans
Emergency information form
Communicating with educators
Transitioning to adult services
Coding, billing and reimbursement
The electronic office
Medical Home Grand Rounds — Chronic Illness: New and Old Ideas (slide show)

Additional information, materials and resources are available through the National Center for Medical Home Initiatives. Specific management recommendations for several chronic conditions are available on the web site of the Utah Medical Home Project and in the book Physicians Guide to Caring for Children with Disabilities and Chronic Conditions by R. Nickel and L. Desch (Eds) Paul Brookes Publishing Co, Baltimore.

Note: The information and resources in this section are provided for educational purposes only. The information is not intended to provide medical advice or professional services and should not be used for treating a health care problem or disease and certainly not a substitute for professional care. If you have questions about some of this information, please talk with your health care provider.

In addition, resources information may change rapidly. If you notice an error in the referral guide or other materials, please contact us.