Medical Home for Patients With Disabilities and Chronic Conditions Improves Access and Self-Management Skills, Leading to More Healthy Days, Fewer Hospitalizations
A primary care medical home for patients
with disabilities and complex, chronic medical conditions emphasizes patient engagement and care coordination among medical specialties and social
service providers, leading to enhanced access to care, better self-management skills, more days of good health, fewer hospitalizations, and lower costs.
Social Workers Support Outpatients in Dealing With Psychosocial Issues, Leading to High Patient and Practitioner Satisfaction and Better Patient Self-Management
Master's-level social workers operating out of a centralized department support primary care and specialty clinic patients in dealing with psychosocial and environmental issues, leading to high levels of patient/caregiver and practitioner satisfaction, improvements in patients’ well-being and self-management skills, and reductions in resource use.
Statewide Medical Home Program for Low-Income Pregnant Women Enhances Access to Comprehensive Prenatal Care and Case Management, Improves Outcomes
A State-based, public–private partnership adapted its successful primary care medical home model to serve pregnant Medicaid beneficiaries, leading to enhanced access to comprehensive prenatal care (including intensive case management for high-risk pregnancies), better adherence to evidence-based care standards, and reductions in low–birth weight babies and rate of primary Cesarean sections.
Community Partners Offer Financial Incentives and Support for Primary Care Practices, Improving Access and Reducing Utilization for Children on Medicaid
The Children's Healthcare Access Program offers financial incentives and support services to primary care medical homes serving children covered by Medicaid and their families; the program enhanced access to primary care, increased the percentage of children with asthma action plans, reduced emergency department visits and hospital admissions, increased well-child visits, and reduced costs.
Hospital Partnership Offers Pathways-Based Case Management Program, Leading to Enhanced Access to Appropriate Care for Uninsured
A joint case management program sponsored by two competing hospitals addresses the health and social needs of uninsured and underinsured individuals who have a history of using the emergency department for nonemergent issues. The program has led to enhanced access to appropriate care and to a significant decline in emergency department use and costs for nonemergent conditions.
Maximizing Health Care for Colorado’s Underserved
This operational handbook for safety-net medical homes describes the experience of Doctors Care, a community-funded, nonprofit organization that helps underserved children, adults, and families receive the medical attention they need.
National Center of Medical Home Initiatives for Children With Special Needs Tools/Resources
This Web site includes a variety of tools for families, youth, providers, insurers, communities, and States working to provide medical homes for children with special needs.
Practice Facilitation Handbook: Training Modules for New Facilitators and Their Trainers
The Practice Facilitation Handbook is designed to assist in the training of new practice facilitators as they begin to develop the knowledge and skills needed to support meaningful improvement in primary care practices.
Systems of Care/Patient-Centered Medical Home Initiative: Primary Care–Specialty Care Compact
The purpose of the compact is to improve care and build and sustain trusted medical neighborhoods through a defined communication protocol.
A Collaborative Partnership: Resources to Help Consumers Thrive in the Medical Home
This guide for health care organizations and stakeholders provides resources to improve consumer participation to help design and inform the needed patient focus of the patient-centered medical home.