CE/CME

Building a Comprehensive and Effective Medical Home

Welcome to the training on Building a Comprehensive and Effective Medical Home provided by the Texas Health and Human Services Commission (HHSC) and the Texas Department of State Health Services (DSHS).

Credit Hours: 1.25 CE

Enroll

Goal

The goal of this module is to equip Texas Health Steps providers and others to build comprehensive and effective medical homes that serve children and adolescents with and without special health-care needs, and regardless of their racial, ethnic, socioeconomic and health status.

Target Audience

Texas Health Steps providers and other interested health-care professionals.

Specific Learning Objectives

After completing the activities of this module, you will be able to:

  1. Summarize key outcomes of medical home implementation for health-care providers, patients, and parents and caregivers.
  2. Specify action steps necessary to build a comprehensive and effective medical home that meets the needs of all patients and families in the primary care practice.
  3. Integrate preventive service components into care delivery in a medical home.
  4. Assess the role of specialists, subspecialists and community resources as part of the medical neighborhood.

Please note this module expires on 7/16/2024.

This module was released on 7/16/2021.

Featured

Adams, S., Cohen, E., Mahant, S., Friedman, J. N., MacCulloch, R., & Nicholas, D. B. (2013). Exploring the usefulness of comprehensive care plans for children with medical complexity (CMC): a qualitative study. BMC Pediatrics, 13(10).

Agency for Healthcare Research & Quality. (n.d.). Patient Centered Medical Home Resource Center.

Agency for Healthcare Research & Quality. (n.d.). 5 Key Functions of the Medical Home

American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, & American Osteopathic Association. (2007). Joint Principles of the Patient-Centered Medical Home. Patient Centered Primary Care Collaborative.

American Academy of Pediatrics. (2021). A Medical Home Where Everybody Knows Your Name.

American Academy of Pediatrics. (2021): Practice Transformation.

American Academy of Pediatrics. (2021). Mental Health Initiatives.

American Academy of Pediatrics. (2021). Mental Health Initiatives, About Us.

American Academy of Pediatrics. (2021). The Resilience Project.

American Academy of Pediatrics. (2021). The Resilience Project: Creating a Medical Home.

American Academy of Pediatrics, healthychildren.org. (2021). Childhood Exposure to Violence.

American Academy of Pediatrics. (2021). Coding for Medical Home Visits.

American Academy of Pediatrics. (2020). Promoting Optimal Development: Identifying Infants and Young Children with Developmental Disorders Through Developmental Surveillance and Screening. Pediatrics, 145(1):e20193449.

American Academy of Pediatrics. (2018). Policy statement: Patient- and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems. Pediatrics, 133(5), e1451-e1460.

American Academy of Pediatrics. (2016). Policy Statement: Poverty and Child Health in the United States.

American Academy of Pediatrics. (2013). AAP Immunization Resources Best Practices.

American Academy of Pediatrics. (2008). Policy Statement: The Medical HomePediatrics, 110:184–186.

American Academy of Pediatrics, National Resource Center for Patient/Family-Centered Medical Home (Formerly the National Center for Medical Home Implementation). (n.d.).

American Academy of Pediatrics, American Academy of Family Physicians, and American College of Physicians, Transitions Clinical Report Authoring Group. (2018). Clinical Report: Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home. Pediatrics, 128(1), 182-200.

American Academy of Pediatric Dentistry. (2021). Definition of Dental Home.

American Board of Pediatrics. (2021). NCQA: Patient-Centered Medical Home or Specialty Practice (PCMH/PCSP).

American College of Physicians. (n.d.). ACP Practice Advisor.

Association of Maternal & Child Health Programs (AMCHP), the National Academy for State Health Policy (NASHP), & the Lucile Packard Foundation for Children’s Health. (2017). Standards for Systems of Care for Children and Youth with Special Health Care Needs Version 2.0.

Center for Medical Home Improvement:

Centers for Disease Control and Prevention. (2020). Vaccine for HPV.

Centers for Disease Control and Prevention. (2020). Public Health Professionals Gateway: The Use of Telehealth and Telemedicine in Public Health.

Cepelewicz, B. B. (2014). Text messaging with patients: Steps physicians must take to avoid liability. Medical Economics, 91(10), 42-3.

Child and Adolescent Health Measurement Initiative. 2019 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB).

Child and Adolescent Health Measurement Initiative. (n.d.). Prior Year NSCH and NS-CSHCN Data Documents and Resources.

Children and Adolescent Health Measurement Initiative (CAHMI). (2021). Children with Special Health Care Needs (CSHCN) Screener.

Children and Adolescent Health Measurement Initiative (CAHMI) CSHCN Screener: Fast Facts.

Desai, A. D., Jacob-Files, E. A., Wignall, J., Wang, G., Pratt, W., Mangione-Smith, R., & Britto, M. T. (2018). Caregiver and Health Care Provider Perspectives on Cloud-Based Shared Care Plans for Children With Medical Complexity. Hospital pediatrics8(7), 394–403.

Garcia-Huidobro, D., Shippee, N., Joseph-DiCaprio, J., O'Brien, J. M., & Svetaz, M. V. (2016). Effect of Patient-Centered Medical Home on Preventive Services for Adolescents and Young Adults. Pediatrics, 137(6):e20153813.

HealthIT.gov: Promoting Interoperability.

Kraft, C. (2014). Healthcare Texting: Right Format for Today's Families. American Academy of Pediatrics (AAP) Experience National Conference & Exhibition.

The National Alliance to Advance Adolescent Health. Gottransition.org. (n.d.). Six core elements of health care transition.

National Resource Center for Patient/Family-Centered Medical Home. (n.d.). Coordinated Care.

National Resource Center for Patient/Family-Centered Medical Home. (n.d.). Family Engagement Quality Improvement Project.

National Resource Center for Patient/Family-Centered Medical Home. (n.d.). Co-Management Letter and Agreement.

National Child Traumatic Stress Network. (2021).

National Committee for Quality Assurance (NCQA). (2021). Patient Centered Medical Home (PCMH) Recognition.

National Committee for Quality Assurance (NCQA). (2019). White paper: How NCQA Patient-Centered Medical Homes Address Disparities.

National Institute for Children’s Health Quality (NICHQ). (2021). Our Body of Work.

Norwood, K. W. & Slayton, R. L. (2018). Clinical Report: Oral health care for children with developmental disabilities. Pediatrics, 113(3), 614-619.

Office of the National Coordinator for Health Information Technology. (2018). Regional Extension Centers.

Patient-Centered Primary Care Collaborative (PCPCC).

Patient-Centered Primary Care Collaborative (PCPCC). (2021). About Us.

Patient-Centered Primary Care Collaborative (PCPCC). (2021). Medical Neighborhood.

Patient-Centered Primary Care Collaborative (PCPCC). (2021). Support and Alignment Network.

Patient-Centered Primary Care Collaborative (PCPCC). (2014). Behavioral Health Integration into the PCMH.

Patient-Centered Primary Care Collaborative (PCPCC). (2014). The Medical Home’s Impact on Cost & Quality, An Annual Update of the Evidence, 2012-2013.

Patient-Centered Primary Care Collaborative (PCPCC). (2017). Behavioral Health Integration in Pediatric Primary Care: Considerations and Opportunities for Policymakers, Planners, and Providers. Sponsored by the Milbank Memorial Fund.

Patient-Centered Primary Care Collaborative (PCPCC). (2017). The Impact of Primary Care Practice Transformation on Cost, Quality, and Utilization.

Peikes, D., Zutshi, A., Genevro, J., Smith, K., Parchman, M., & Meyers, D. (2012). Early Evidence on the Patient-Centered Medical Home. Final Report. AHRQ Publication No. 12-0020-EF. Rockville, MD: Agency for Healthcare Research and Quality.

Sharifi, M., Dryden, E. M., Horan, C. M., Price, S., Marshall, R., Hacker, K., Finkelstein, J. A., & Taveras, E. M. (2013). Leveraging text messaging and mobile technology to support pediatric obesity-related behavior change: a qualitative study using parent focus groups and interviews. Journal of Medical Internet Research, 15(12), e272

Storck, L. (Feb 2017). Policy Statement: Texting in HealthcareOnline Journal of Nursing Informatics (OJNI), 21(1).

Texas Department of State Health Services. (2017). Children with Special Health Care Needs (CSHCN) Services Program community-based partner organizations.

Texas Health and Human Services Commission. (2021). Children with Special Health Care Needs (CSHCN) Services Program.

Texas Health and Human Services Commission. (2021). First Dental Home.

Texas Health and Human Services Commission. (2021). Medical Home Learning Collaborative.

Texas Health and Human Services Commission. (2021). Mental Health Screening Tools. Texas Health Steps.

Texas Health and Human Services Commission. (2021). Texas Health Steps.

Texas Health and Human Services Commission, Children with Special Health Care Needs (CSHCN) Services Program. (2021). Family Support Services.

Texas Health and Human Services Commission. (2021). Anticipatory Guidance Provider Guide. Texas Health Steps.

Texas Health and Human Services Commission. (2021). Children’s Mental Health Child & Youth Assessment Services.

Texas Health and Human Services Commission. (2021). Oral Evaluation & Fluoride Varnish in the Medical Home.

Texas Health and Human Services Commission. (2021). Texas Health Steps Clinical Record Review Tool.

Texas Health and Human Services Commission. (2021). Texas Health Steps Medical Providers .

Texas Health and Human Services Commission. (2021). Dental Providers.

Texas Medicaid & Healthcare Partnership. (2021). Texas Medicaid Provider Procedures Manual.

Texas Medicaid & Healthcare Partnership. (2021). Texas Medicaid Provider Procedures Manual, Telecommunication Services Handbook.

Texas Medicaid & Healthcare Partnership. (2021). Texas Medicaid Provider Procedure Manual (TMPPM), Children’s Services Handbook.

Texas Occupations Code, Sec. 111.001.

Texas Parent to Parent (TxP2P.org).

U.S. Census Bureau. (2019) Quick Facts – Texas.

U.S. Department of Human Services, HealthIT.gov. (2019). Promoting Interoperability.

U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2011). White paper: Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms.

U.S. Department of Human Services, Office of Disease Prevention and Health Promotion. (n.d.). Healthy People 2030: Social Determinants of Health.

U.S. Department of Health and Human Services. (n.d.). Certified Health Information Technology (IT) Product List.

USF (University of South Florida) Health, Morsani College of Medicine. (2020) Three Resources for Meaningful use Requirements.

Willcox, J. C., Dobson, R., & Whittaker, R. (2019). Old-Fashioned Technology in the Era of "Bling": Is There a Future for Text Messaging in Health Care?Journal of medical Internet research21(12), e16630.

Additional

American Academy of Pediatrics, Medical Home Initiatives for Children With Special Needs Project Advisory Committee. (2002, Reaffirmed 2008). Policy statement: The medical home. Pediatrics, 110(1), 184-186.

Boudreau, A. A., Goodman, E., Kurowski, D., Perrin, J. M., Cooley, W. C., & Kuhlthau, K. (2014). Care Coordination and Unmet Specialty Care Among Children With Special Health Care Needs. [Abstract]. Pediatrics, 133(6). 1046-1053.

Elliott, V. S. (2012). Can a specialty practice be a patient-centered medical home? American Medical News.

Homer, C. J. & Baron, R. J. (2010). How to Scale Up Primary Care Transformation: What We Know and What We Need to Know? Journal of General Internal Medicine, 25(6), 625-629.

McManus, M. A., Pollack, L. R., Cooley, W. C., McAllister, J. W., Lotstein, D., Strickland, B., & Mann, M. Y. (2013). Current Status of Transition Preparation Among Youth With Special Needs in the United States. Pediatrics, 131(6), 1090-1097.

Mosquera, R. A., Avritscher, E. C., Samuels, C. L., Harris, T. S., Pedroza, C., Evans, P., . . . J. E. (2014). Effect of an Enhanced Medical Home on Serious Illness and Cost of Care Among High-Risk Children With Chronic Illness: A Randomized Clinical Trial. [Abstract.] Journal of the American Medical Association, 312(24). 2640-2648.

Schiavo, J. H. (2011). Oral Health Literacy in the Dental Office: The Unrecognized Patient Risk Factor. Journal of Dental Hygiene, 85(4), pp. 248-255.

Sia, C., Tonniges, T. F., Osterhus, E., & Taba, E. (2004). History of the Medical Home Concept. Pediatrics, 113(5):1473.

Helpful Resources

Parent Companion First Five Years, a bilingual website focusing on young children with disabilities that was created to comfort, inspire and connect parents to helpful disability resources.

Parent to Parent of New York State. (2013). Tip Sheets for Caregivers of Individuals with Special Health Care Needs.

Texas Health and Human Services Commission. (2021). Services for Caregivers.

Continuing Medical Education

The Texas Department of State Health Services, Continuing Education Service is accredited by the Texas Medical Association to provide continuing medical education for physicians. 

The Texas Department of State Health Services, Continuing Education Service designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The Texas Department of State Health Services, Continuing Education Service is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. The Texas Department of State Health Services, Continuing Education Service has awarded 1.25 contact hour(s) of Continuing Nursing Education.

Social Workers

The Texas Department of State Health Services, Continuing Education Service, the continuing education provider, ensures that the education provided is directly related to the practice of social work; and that the individuals presenting the information have the necessary experience and knowledge in the topics presented. The Texas Department of State Health Services, Continuing Education Service has awarded 1.25 hours of credit.

Certificate of Attendance

The Texas Department of State Health Services, Continuing Education Service has designated 1.25 hour(s) for attendance.

Certified Community Health Worker

The Texas Department of State Health Services, Promotor(a)/Community Health Worker Training and Certification Program has certified this course for 1.25 contact hour(s) of continuing education for Certified Community Health Workers and Community Health Worker Instructors.

General Disclosure

One of the requirements of continuing education is disclosure of the following information to the learner:

  1. Notice of requirements for successful completion of continuing education activity. To receive continuing education credit the learner must successfully complete the following activities:
    • Create a Texas Health Steps account.
    • Complete on-line registration process.
    • Thoroughly read the content of the module.
    • Complete the on-line examination.
    • Complete the evaluation.
  2. Commercial Support.
    The THSTEPS Web-based Continuing Education Series has received no commercial support.
  3. Disclosure of Relevant Financial Relationships.
    The THSTEPS Continuing Education Planning Committee and the authors of these modules have no relevant financial relationships to disclose.
  4. Non-Endorsement Statement.
    Accredited status does not imply endorsement of any commercial products or services by the Department of State Health Services, Continuing Education Service; Texas Medical Association; or American Nurse Credentialing Center.
  5. Off-Label Use.
    Using a disclosure review process, the THSTEPS Continuing Education Planning Committee has examined documents and has concluded that the authors of these modules have not included content that discusses off-label use (use of products for a purpose other than that for which they were approved by the Food and Drug Administration).

The following are policies and definitions of terms related to continuing education disclosure:

The intent of disclosure is to allow Department of State Health Services (DSHS) Continuing Education Service the opportunity to resolve any potential conflicts of interest to assure balance, independence, objectivity and scientific rigor in all of its Continuing Education activities.

All faculty, planners, speakers and authors of Department of State Health Services (DSHS) Continuing Education Service sponsored activities are expected to disclose to the Department of State Health Services (DSHS) Continuing Education Service any relevant financial, relationships with any commercial or personal interest that produces health care goods or services concerned with the content of an educational presentation. Faculty, planners, speakers and authors must also disclose where there are any other potentially biasing relationships of a professional or personal nature.

Glossary of Terms

Conflict of Interest: Circumstances create a conflict of interest when an individual has an opportunity to affect Continuing Education content about products or services of a commercial interest with which she/he has a financial relationship or where there are any other potentially biasing relationships of a professional or personal nature.

Commercial Interest: Any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

Financial Relationships: Those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, teaching, membership on advisory committees or review panels, board membership, and other activities for which remuneration is received or expected. Relevant financial relationships would include those within the past 12 months of the person involved in the activity and a spouse or partner. Relevant financial relationships of your spouse or partner are those of which you are aware at the time of this disclosure.

Off Label: Using products for a purpose other that that for which it was approved by the Food and Drug Administration (FDA).

Texas Health Steps courses are best viewed using a current browser. If you are using an out-of-date browser or a version of Internet Explorer less than 11, lesson progress and interactive features may not function properly.

Health-Care Providers

Agency for Healthcare Research and Quality (AHRQ).

American Academy of Pediatrics:

Center for Medical Home Improvement:

American Academy of Pediatrics, the American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP). (2018). Health care transition-planning algorithm for all youth and young adults within a medical home interaction.

American College of Physicians. (n.d.). ACP Practice Advisor.

Centers for Disease Control and Prevention. (2020). Vaccine for HPV.

Centers for Disease Control and Prevention. HPV fact sheets and brochures.

Family Voices. Family Engagement in Systems Toolkit.

National Alliance to Advance Adolescent Health:

National Committee for Quality Assurance (NCQA). (2021). Patient Centered Medical Home (PCMH) Recognition.

National Committee for Quality Assurance. Webinar: Addressing Health Care Disparities with Patient-Centered Medical Homes.

Oral health terms in plain language: Schiavo, J. H. (2011). Oral Health Literacy in the Dental Office: The Unrecognized Patient Risk Factor. Journal of Dental Hygiene, 85(4), pp. 248-255.

Patient-Centered Primary Care Collaborative (PCPCC).

Patient-Centered Primary Care Collaborative (PCPCC). (2017). Behavioral Health Integration in Pediatric Primary Care: Considerations and Opportunities for Policymakers, Planners, and Providers. Sponsored by the Milbank Memorial Fund.

Patient-Centered Primary Care Collaborative (PCPCC). Clinical Practice Transformation Quick Start Guide, with resources about diverse topics. Resources are presented in video learning modules, templates, checklists, webinars, toolkits and other formats.

Standards for Systems of Care for Children and Youth with Special Health Care Needs, a groundbreaking set of national standards designed to build and improve systems of care for children and adolescents with special health-care needs. Sponsored by the Association of Maternal & Child Health Programs and the National Academy for State Health Policy.

Texas Department of State Health Services. Medical Home Learning Collaborative (MHLC).

Texas Health and Human Services Commission:

Texas Health Steps:

Texas Medicaid:

Texas Parent to Parent (TxP2P) is a parent-led statewide nonprofit dedicated to improving the lives of Texas children who have special health-care needs such as disability and chronic illness. TxP2P provides programs and resources for families, and educates medical professionals about the children’s unique needs in order to improve care. The group’s Medical Education Program (MEd) teaches pediatric and family practice residents and other medical professionals the skills needed to partner with the family to provide high-quality care.

U.S. Department of Health and Human Services. Certified Health Information Technology (IT) Product List website lists certified EHR products eligible for use.

U.S. Office of the National Coordinator for Health Information Technology offers Health Information Technology Regional Extension Centers (RECs). These RECs help health-care providers quickly become adept users of EHRs. Find the RECs located in Texas.