Discover a collection of tools and resources for pediatric practices interested in learning more about the pediatric medical home.

Getting Started

The following resources support pediatric clinicians and practice teams in pediatric medical home implementation:

Family-Centered Care

Provision of family-centered care is a key function of a pediatric medical home. At its core, the pediatric medical home acknowledges and respects that families are the primary caregivers, experts, and supports for their child.

Family-centered care honors the strengths, cultures, traditions, and expertise that family members bring to the medical home team and fosters a respectful partnership between families and clinicians.

The following are resources for child health professionals interested in implementing and enhancing family-centered care:

Care Coordination

Care coordination involves the "deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services."

The following is a list of resources for child health professionals and others interested in implementing and enhancing care coordination:

For more information about care coordination, including the National Center for Care Coordination Technical Assistance, visit the care coordination page.

Care Planning

A care plan, or a medical summary, assists with the implementation of successful care coordination within a pediatric medical home. A comprehensive care plan includes all historical, medical, and social aspect of a child and family's needs. It also includes the following:

  • Key interventions
  • Roles and responsibilities of each care team member
  • Contact information

In a pediatric medical home, a care plan should be created in partnership with the family and youth. The following is a list of resources that can be used when creating and implementing a shared plan of care within a pediatric medical home:

Culturally Competent Care

A family’s cultural background—including beliefs, rituals, and customs—are recognized, valued, and respected within a pediatric medical home. All efforts are made to ensure that the child or youth and family understand the details of the medical encounter and the care plan.

The following resources are available to help with implementation and enhancement of culturally competent care:

Team-based Care

Team-based care improves communication and health care for patients and families. The following resources are available to help with the implementation of team-based care:

Transition to Adult Care

​Health care transition is the process of moving from a child to an adult model of care with or without transfer to a new clinician. For pediatric practices, this includes the following:

  • creating a transition policy for the practice
  • identifying transition-aged youth
  • leading routine transition readiness/self-care skill assessments
  • including transition needs into a plan of care
  • preparing a medical summary
  • helping to identify adult providers
  • preparing a transfer package
  • ensuring the transfer is completed
  • measuring progrerss of the transition implementation process​
  • eliciting feedback from youth and families

Pediatricians can use the following resources to support youth transitioning from pediatric to adult care:

For more information about transitions of care, including Got Transition, the Center for Health Care Transition Improvement, visit www.gottransition.org.

Measuring and Paying for Your Medical Home

Practices that provide care consistent with a medical home approach are well positioned to advocate and negotiate for improved and appropriate payment. The following resources focus on payment for medical home activities within a practice:

Online Implementation Guides for Pediatric Practices and Professionals

Many organizations have created online resource guides, toolkits, and training opportunities for clinicians and practices implementing medical home. The following is a collection of these resources:

Last Updated

01/08/2025

Source

American Academy of Pediatrics