Welcome to the Minnesota Chapter
American Academy of Pediatrics

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Inside this Issue:

- Minnesota Medical Home Report
- Miriam Buck: A Miracle in the Making
- Integrated Community Systems of Care for CYSHCN - A Major New Initiative
- Making the Case for Medical Home: A Review of the Evidence

Minnesota Medical Home Report

This article appeared in the Fall/2004 issue of Minnesota Pediatrician

Knowing only that they were participating in “an exciting endeavor to continue to develop their practices as a medical home,” 11 teams - each comprised of a physician, two parents and a care coordinator/ nurse - came together in mid-March to start a year long collaborative learning process to realize medical home improvements.

The teams were put together by 11 physicians - all pediatricians - who were among the 50 physicians who responded to a letter sent out from The Minnesota Chapter of the AAP, PACER Center and the Minnesota Department of Health, inviting them to participate in a project to ensure that children with special health care needs (CSHCN) receive coordinated, ongoing, comprehensive care within a medical home. In agreeing to participate, the 11 teams committed to three retreats and three action periods — basically a year of very hard work.

When the teams gathered in Minneapolis for their second two-day learning session in July, they shared the impressive progress they’d made in only four months. Dr. Alan Kohrt, one of the featured faculty for the July Learning Session, wrote after the session that “the practices are spectacular and have done such a great job.” Dr. Kohrt, a Clinical Associate Professor of Pediatrics at The Children’s Hospital of Philadelphia and the University of Pennsylvania School of Medicine, served as a consultant and faculty member on the National Medical Home Learning Collaborative, was a co-author of the original AAP statement on the Medical Home, and is the Pennsylvania program coordinator working with 20 practices developing Medical Homes.

The challenge to the 11 practices at the end of the March learning session had been to focus on care partnerships and identifying children with special health care needs. During the following action period, all the teams had identified almost 900 children with special health care needs. Care coordination, special appointment times, and developing care and emergency plans cannot happen for children who are not identified; that is, “flagged” somehow in a practice’s system.

The other focus of the teams was on “care partnerships.” Each team was set up as a partnership of providers and families. Between the March and July learning sessions, some teams met weekly while others met monthly. It was clear from the discussions and evaluations at the July Learning Session that there were indeed real partnerships emerging. The Owatonna team’s presentation at the July Learning Session stated that the “main benefit” of the process so far “has been identifying this need and bonding with the families of children with special health care needs.” A comment from one of the parents to a question about the most significant impact since the March Learning Session in patient outcomes summed up the feeling as the teams gathered for a second time: “Networking — Most of all CHANGES and support for us families.”

The teams made progress in many other areas as well. Some examples include:

• CentraCare Women and Children’s Clinic in St. Cloud has done the most to “hard-wire” changes into the entire clinic’s system. Specifically, they began the process of identification of CSHCN with manual lists first, determining which children to enter into the central system, and within a fairly short time, entering all the children flagged as CSHCN into the central system. Ongoing identification and flagging is done as children come in for visits. They were also able to develop, test and implement a care plan for the most involved CSHCN. Further, the team has implemented a separate Asthma Care Plan process. Soon after the learning session, CentraCare was able to get three hours per week of care coordination. The care coordinator’s initial work is to streamline the process of getting care plans in place, and to involve other providers in the care planning process.
• The Park Nicollet Clinic in Plymouth is working on developing a parent advisory group and is identifying ways to integrate a care plan into the new electronic medical records system of the clinic. Soon after the July learning session, a very successful first parent advisory group met, where 15 parents of CSHCN made valuable input into what a care plan should include, how the clinic’s triage system could be made more effective, and how they would use care coordination for their children. The group will be very effective advocates in the future for the changes envisioned by the team.
• Grand Itasca Clinic in Grand Rapids was able to recruit 30 children to attend a day long “asthma camp” - a significantly more successful camp than ever before. Also, the promise of getting a care coordinator position within the clinic is an exciting prospect.
• The North Point Health and Wellness Center team (formerly the Pilot City Clinic team) is working with Southeast Asian CSHCN and their families. A focus group met and parents identified issues including: parents not knowing what resources were available; long waiting times; clinic phone line difficult to use; lacking communication/ educational tools both at school and at home.
• The Regina Medical Center has adopted an Emergency Care form and is completing them for their CSHCN. A parent on the team developed a special tube that attaches to a child’s wheel chair with Velcro to hold the Emergency Care plan. Following the learning session, the physicians were able to begin developing care plans for the most involved CSHCN.
• The Brainerd team devised a system to route calls for identified CSHCN directly to a staff person working with the team’s medical providers. The practice team also modified its health history dictation system so that it could serve as a care plan as well. Following transcription, a system was devised so that one copy of the “health history” went into a notebook, one into the chart, one to the parent, and one to the emergency room.
• The Owatonna Clinic has identified each CSHCN with a special stamp in their chart and by a pop up note in the computer. A dedicated time slot of 30 minutes is held open each day for a CSHCN. The practice had completed four emergency care plans and copied the parents through e-mail and hard copy, and copied the emergency room at the Owatonna Hospital and Ambulance Service. The practice is testing a Fax-Back for specialty visits and has had some positive results. The clinic receptionists are being trained to ask specific questions of CSHCN families. The practice was successful in having a direct phone line set up to the care coordinator and to the information desk so CSHCN parents can have easy access.
• The New Ulm practice team has identified 110 CSHCN as of the July meeting and they are flagged in the clinic system, the hospital system and the emergency room. The New Ulm team pediatrician has created a database for emergency care plans and for asthma action plans. The Emergency Care plans are on a CD-ROM in the E.R. When asthma medications are updated on the database, the emergency care plan is automatically updated. The New Ulm team also has developed a newsletter, became proactive in providing care coordination, conducted a parent focus group, created a Fax-Back Form for subspecialists so they can Fax their findings and recommendations immediately after a visit, and started a website to host CSHCN resources.
• The Lakeview Team in Watertown has been meeting with people from the schools and community. By including people from the community on the team, new channels of communication between the practice and community have been opened. The Lakeview team has also implemented one-hour time slots for some CSHCN and a direct clinic telephone line for families of CSHCN.
• The Alexandria Clinic team was able to test and implement care plans for their CSHCN. They were surprised by how much families loved them. Parents as partners were involved with the Alexandria clinic in a unique way — providing input on how to re-design the entryway to the building so that it will be easier to get a child out of a car and into the building.
• The Mankato clinic team devised a resource board at the clinic with information for families, collaborated with some of the psych services within the clinic, tested an autism screening tool, and tested a medical summary sheet which is going through administrative channels for approval prior to implementation.

While some teams have found the process difficult, some have found it surprisingly smooth. Dr. Marilyn Peitso from the CentraCare Women’s and Children’s practice team noted that the process had been made smoother because there was support from the top on down, that families were eager to participate, and “the more we do, the more people get excited.”

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Miriam Buck: A miracle in the making

Printed with permission from Owatonna Clinic - Mayo Health System Hometown Health newsletter Fall/2004

By the first time 3-year-old Miriam Buck pointed at her father and told him, “No!,” he was overjoyed.

“A lot of parents might be irritated, but we celebrated,” says Dan Buck. “We were told Miriam would never walk or talk, so we are thrilled whenever she does things normal for children her age.”

Miriam was born with tuberous sclerosis (TS), a genetic disorder that causes benign tumors to form in the heart, brain, kidneys, eyes, skin and lungs. It is estimated that one in every 6,000 children is born with TS. In some, the disease may cause no symptoms and go undiagnosed for years. In others, such as Miriam, the condition is immediately life threatening.

“Miriam is a miracle,” says Mary Rahrick, M.D., a pediatrician at Owatonna Clinic - part of Mayo Health System. “It has been amazing to see this child, who was not expected to survive infancy, now thriving.”

A normal pregnancy
Dan and Jennifer Buck already had three children - adopted son Reese, then 9; son Caleb, then 4; and daughter Elisabeth, then 3 - when Jennifer Buck learned she was pregnant with Miriam. The pregnancy, like her first two, seemed normal in every regard.

It wasn’t until Buck went into labor that she - or her family physician at Owatonna Clinic, Richard Griffin, M.D. - knew there was any problem with the baby she was carrying.

“Miriam’s heartbeat varied between 60 and 260 beats per minute during labor,” says Buck.

A normal fetal heartbeat is between 110 and 160 beats per minute.

“As soon as she was born, Dr. Griffin took Miriam away for testing,” says Buck.

Dr. Griffin returned to tell the couple that their daughter’s heart, which should have been about the size of a small orange, was as big as a large grapefruit. Dr. Griffin recommended the Bucks immediately send Miriam to a hospital in the Twin Cities for further testing and specialty care.

An ambulance rushed Miriam to the Twin Cities, and her parents followed in their car. By the time the couple reached the hospital, physicians had begun examining Miriam and were fairly certain she had TS. She had 16 tumors in her heart and six dozen tumors in her brain. The physicians had never seen such an aggressive form of TS and told the Bucks it was unlikely Miriam would survive.

But the physicians had never met anyone like Miriam.

A fighter
The tumors in Miriam’s heart were inoperable and caused significant stress on her heart. She frequently went into cardiac arrest, and her heart would restart when she curled into a fetal position and kicked her tiny legs. Physicians worked around the clock to find a combination of medications to stabilize Miriam’s heart.

After two weeks, they were successful.

“We’d never dealt with any doctor except our family physician,” says Jennifer Buck. “We were overwhelmed by all of the specialists caring for Miriam.”

When she was nearly 1 month old, Miriam was stable enough to go home.

“Dr. Mary is our angel,” says Jennifer Buck. “She stays on top of Miriam’s immunization schedule, communicates with all the specialists and is available whenever Miriam needs her.”

Miriam’s short life has been a series of highs and lows. At 6 months old, Miriam began having seizures — sometimes as many as 150 a day and once for 48 hours straight — from the tumors in her brain. The seizures are now controlled by medication and a special diet.

Miriam has begun to develop tumors on her eyes and kidneys.

While most children who have such severe TS have serious developmental delays, Miriam is only a year behind other children her age. She turned 5 in April, and last summer became a big sister to Ezra.

“When Ezra was born, Miriam just blossomed,” says Jennifer Buck. “She’s no longer the baby in the family. It’s been the biggest step in her life.”

The night Miriam was born, her father began researching TS and learned most children born with the disease don’t live past their teens or early 20s. That knowledge has intensified his relationship with his daughter.

“I realized early on that we might not have Miriam for very long,” says Dan Buck. “Her illness has given me a chance to share with her what many parents don’t get to share with their kids. When you have a child who has special needs, I think you buckle down. You don’t take things for granted.”

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Medical Home Project – coordinating the care of children who have special needs

Caring for a child who has special health needs can be overwhelming - countless medical appointments, unexpected trips to the emergency room, long lists of medications to track and seemingly endless paperwork.

Parents often navigate these unfamiliar waters on their own. A new pilot program sponsored by the Minnesota Department of Health offers help to families in this situation.

“Through the Medical Home Project, we’re trying to ease the burden on parents and provide support as they work their way through the medical system,” says Mary Rahrick, M.D., a pediatrician who coordinates the program at Owatonna Clinic. Helping Dr. Rahrick coordinate the program at Owatonna Clinic are a nurse and parents of children who have special needs, including Dan and Jennifer Buck. Medical Home Project provides these services:

• A physician who coordinates the child’s care
• A tip sheet with the coordinating physician’s work hours and contact information
• A form to take to all medical appointments to be completed by providers and immediately faxed to the coordinating physician for review
• Special attention when scheduling appointments to determine if extra time or assistance upon arrival at the clinic is needed
• Assistance developing a care plan for the child, including a health history and emergency contact information

“Parent support of this program, a work in progress, is overwhelmingly positive,” says Dr. Rahrick. “We hope to expand it to include more physicians next year.”

For information about the Medical Home Project, contact Dr. Rahrick at Owatonna Clinic, 507-451-1120.

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Integrated Community Systems of Care for CYSHCN -
A Major New Initiative

The Minnesota Department of Health’s (MDH) Minnesota Children with Special Health Needs (MCSHN) program has applied for a grant through “The President’s New Freedom Initiative: State Implementation Grants for Integrated Community Systems of Services for CSHCN.”

The purpose of the New Freedom initiative is to support statewide implementation of Community-Based Systems of Services for Children and Youth with Special Health Care Needs (CYSHCN). Under the initiative, the Federal Maternal and Child Health Bureau has the lead in developing and implementing a plan to achieve appropriate Community-Based Service Systems, as defined by the following components: (1) family/ professional partnership; (2) comprehensive health care through a medical home; (3) access to adequate health insurance/financing; (4) early and continuous screening; (5) organization of community services for easy use by families; and (6) transition to adult health care, work, and independence.

If funded, the project would begin in May of 2005. It will be a partnership between MCSHN, the Minnesota Chapter of the American Academy of Pediatrics, PACER Center and its Family Voices of Minnesota, Healthy and Ready to Work, and Children’s Mental Health Services at the Department of Human Services.The partners hope to enlist other partner organizations as the project unfolds. The partners will work closely with other programs within MDH and the Department of Education through workgroups targeted to the six outcomes. The Wilder Research Center will evaluate the project.

The goal of the proposed project is to integrate the six core components into a comprehensive, coordinated and community driven system of care that has informed, activated CYSHCN and their families at the center of the care system.

Objectives are:

1. The development and mobilization of policy and practice partners among physicians, state level government program leaders, youth and families of CYSHCN who will all effectively promote changes and advance adoption of best practices in systems of care for CYSHCN;
2. The expansion of Medical Home in Minnesota both in breadth and depth, including adoption of best practices for transitioning youth to all aspects of adult life, including adult health care, work and independence.
3. The assurance that medical care practices providing coordinated, comprehensive, family centered care to CYSHCN are reimbursed appropriately for care coordination, care plans, preventive services and coordination with community services;
4. The elimination of disparities in access and outcomes between CYSHCN and their same age peers without health care needs and elimination of disparities among CYSHCN because of linguistic, cultural or financial barriers.

• Build on and expand on the momentum of existing efforts, including the Medical Home Learning Collaborative.


• Build the “infrastructure” for families, youth, and physicians to participate more actively in the design of systems and in the decisions affecting care to CYSHCN through (1) a Parent Council facilitated by Family Voices of Minnesota, (2) a Pediatric Council, (3) a Youth Advisory Board, (4) by enhancing the capacity of the Minnesota Chapter of the American Academy of Pediatrics (MN-AAP), and (5) by utilizing the “Breakthrough Series” process and the “Model for Improvement” to ensure aims of the many individuals and groups working cooperatively are realized through small changes made continuously throughout the project.

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  Healthy People 2010 — Six Critical Indicators The six components that define a system of services for CYSHCN are the same as the “six critical indicators” for progress towards Health People 2010. The following is a list of those six outcomes or indicators and the national centers that have been funded to provide help to projects throughout the Nation in achieving these goals. All CSHCN will receive regular ongoing comprehensive care within a medical home.     The National Center of Medical Home Initiatives for CSHCN: http://www.medicalhomeinfo.org All families of CSHCN will have adequate public and/or private insurance to pay for the services that they need.     The National Center on Financing for CSHCN: http://cshcnfinance.ichp.edu/     The Maternal and Child Health Policy Research Center: http://mchpolicy.org All children will be screened early and continuously for special health care needs.     National Center for Hearing Assessment and Management: http://www.infanthearing.org;     The National Newborn Screening and Genetics Resource Center: http://genes-r-us.uthscsa.edu/ Families of CSHCN will participate in decision making at all levels and will be satisfied with the services that they receive.     Family Voices: http://www.familyvoices.org;     National Center for Cultural Competence: http://www.georgetown.edu/research/gucdc/nccc/ Community-based service systems will be organized so that families can use them easily.     Champions for Progress Center: http://championsforprogress.org All youths with special health care needs will receive the services necessary to make transitions to all aspects of adult life.      Healthy and Ready to Work National Center: http://www.hrtw.org

  “Concentrate on meeting the needs of children and families rather than the needs of organizations.”

  - one of the “Rules of Improvement” from the Model for Improvement

  

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  Making the Case for Medical Home: A Review of the Evidence

  The following information was provided by Lauri Levin, MSW, Technical Assistance Manager, National Center of Medical Home Initiatives for CSHCN, Division of Children with Special Needs American Academy of Pediatrics.

  Overview
  In 2002, the American Academy of Pediatrics (AAP) released a statement calling for a medical home for all children with special health care needs (CSHCN). This statement came in recognition that the American health care system has been spinning out of control in terms of both organization and cost. Although the term “medical home” may be considered new by some, it is a term that has evolved over the past 20 years. It embodies all that we know that health care can and should be for families and child health care professionals: accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective. The medical home is a vision for how all individuals who are involved in the delivery of health care services can partner with their patients and their patients’ families to help them achieve their maximum potential. It includes a seamless system of health care services that fosters collaboration and cooperation among all members of the community in which the child and the family live.¹

  As defined by the Federal Maternal and Child Health Bureau (MCHB), CSHCN have or are at increased risk for chronic physical, developmental, behavioral, or emotional conditions that require health and related services of a type or an amount beyond that required by children generally.CSHCN have almost 2.5 times as many contacts with physicians, and they account for five times as many hospital days per 1,000 as children generally. The comprehensive health needs of these children and adolescents do not fit with the services traditionally offered by the primary care system, which is designed for the 80% of children who do not have special needs. Primary care practices are organized to provide routine well-child care and acute illness management based on the individual patient–provider encounter. Well-child and preventive care for CSHCN must include a model of chronic condition management. Chronic condition management requires the capacity to identify and monitor CSHCN, coordinate and systematically plan for their care, collaborate with specialists and community agencies, and advocate for their needs, all in partnership with their families.²

  National Data on Access to Medical Home
  The 2001 National Survey of Children With Special Health Care Needs represented an unprecedented opportunity to establish uniform prevalence estimates for CSHCN and to gather essential information on how this population of children and families fares in the current health care environment. A major component of the survey addresses the medical home.

  Five criteria, selected to reflect the characteristics of a medical home as defined by the AAP policy statement on the medical home, were analyzed to describe the extent to which CSHCN receive care characteristic of the medical home concept. These criteria included having (1) a usual place for sick/well care, (2) a personal doctor or nurse, (3) no difficulty in obtaining needed referrals, (4) needed care coordination, and (5) family-centered care received. Items from the Survey were selected and clustered to characterize each of the five components.

  Results of the survey indicate that (1) approximately half of CSHCN receive care that meets all five components established for medical home; (2) most CSHCN have a usual source of care and a personal doctor or nurse, but other components of the medical home, especially elements of care coordination and family-centered care, are lacking; (3) access to a medical home issignificantly affected by race/ethnicity, poverty, and the limitations imposed on daily activity by the child’s special health care need; and (4) parents of children who do have a medical home report significantly less delayed or forgone care, significantly fewer unmet health care needs, and significantly fewer unmet needs for family support services.³

  Data for Minnesota were reported in the last issue of Special Connections: only 48.7% of CSHCN have a medical home, putting Minnesota at 44th in the nation.

  Barriers to the Medical Home
  Nationally, as the medical home concept evolved and gained greater recognition, barriers to implementing a medical home for all children became apparent. Three major barriers in implementing the concept were (1) training pediatricians to understand the medical home concept; (2) communication and care coordination for related services in health, family support, and education/special education; and (3) reimbursement for periodic well-child supervision and care coordination.⁴

  The Cost and Quality Benefits of Providing a Medical Home
  

  International and National Data
  International and within-nation studies indicate that a relationship with a medical home is associated with better health, on both the individual and population levels, with lower overall costs of care and with reductions in disparities in health between socially disadvantaged subpopulations and more socially advantaged populations. Although important in facilitating use overall, insurance does not guarantee a medical home.

  The National Survey of CSHCN
  The greater the extent to which a wide range of services are provided by primary care practitioners and a family orientation of these services are associated with better health outcomes at lower costs.

  In three major metropolitan areas of the United States, a lower rate of pediatric hospitalizations was found in communities in which primary care physicians are more involved in the care of children before and during hospitalization.

  Having a regular source of care was found to be the most important factor associated with receiving preventive care services, even after considering the effect of demographic characteristics, financial status, and need for ongoing care. Receiving optimal primary care (in terms of availability, continuity, comprehensiveness, and communication) from the regular source of care further increases this likelihood. ⁷

  Medical Home Primary Care Networks Data
  In the Pediatric Alliance for Coordinated Care (PACC), six pediatric practices introduced interventions to operationalize the medical home for CSHCN. The intervention consisted of a designated pediatric nurse practitioner acting as case manager, a local parent consultant for each practice, the development of an individualized health plan for each patient, and continuing medical education for health care professionals. The objectives of this study were (1) to characterize CSHCN in the PACC, (2) to assess parental satisfaction with the PACC intervention, (3) to assess the impact on hospitalizations and emergency department episodes, and (4) to assess the impact on parental workdays lost and children’s school days lost for CSHCN before and during the PACC intervention.

  Methods. A total of 150 CSHCN in six pediatric practices in the Boston area were studied. Participants were recruited by their pediatricians on the basis of medical/developmental complexity. Physicians completed enrollment information about each child’s diagnosis and severity of condition. Families completed surveys at baseline and follow-up (at two years), assessing their experience with health care for their children.

  Results. A total of 60% of the children had more than five conditions, 41% were dependent on medical technology, and 47 percent were rated by their physician as having a “severe” condition. A total of 117 (78%) families provided data after the intervention. The PACC made care delivery easier, including having the same nurse to talk to (68%), getting letters of medical necessity (67%), getting resources (60%), getting telephone calls returned (61%), getting early medical care when the child is sick (61%), communicating with the child’s doctor (61%), getting referrals to specialists (61%), getting prescriptions filled (56%), getting appointments (61%), setting goals for the child (52%), understanding the child’s medical condition (56%), and relationship with the child’s doctor (58%). Families of children who were rated “severe” were most likely to find these aspects of care “much easier” with the help of the pediatric nurse practitioner. Satisfaction with primary care delivery was high at baseline and remained high throughout the study. There was a statistically significant decrease in parents missing >20 days of work (26% at baseline; 14.1% after PACC) and in hospitalizations (58% at baseline; 43.2% after PACC). The approximate cost per child per year of the intervention was $400.

  Medical Home Primary Care Practices Data
  In a recent study, the cost of unreimbursable care coordination services for CSHCN was determined in one community-based, general pediatric practice. On the basis of national salary and benefits data, the annual cost of the time spent coordinating care for CSHCN in this medical home model ranged from $22,809 to $33,048 (representing the 25th and 75th percentiles, respectively).

  Conclusions. The costs of providing care coordination services to CSHCN in a medical home are appreciable but not prohibitive. Standardization of care coordination practices is essential because it makes the medical home more amenable to quality improvement interventions. Mechanisms to finance unreimbursable care coordination activities must be developed to achieve the Healthy People 2010 objective that all CSHCN have access to a medical home. ⁶

  South Carolina’s Case Study of their First Medical Home Mentor Site (June, 2004)
  The Data: “Specifically, Medicaid data is used to examine office visits, inpatient hospitalizations, emergency room visits, pharmacy claims, and dental services. A comparison group matched on demographic, diagnostic, and health service utilization descriptors was created . . . . The most dramatic difference, which was statistically significant, was the rate of emergency room visits resulting in inpatient hospitalizations for the case group from the pre-medical home quarters (1-4) to the medical home year quarters (5 -8).” ⁹

  Comprehensive Care in an Ambulatory Care Setting
  A study published in 1999 documented that a comprehensive program of care for CSHCN, including developmental disabilities, can improve outcomes by reducing secondary complications and thereby reduce costs. This study suggests that directing financial resources to ambulatory, comprehensive care teams seems to have reduced admission for children with chronic conditions and reduced the average length of stay. Hospital inpatient charges fell significantly, resulting in a savings to insurers of $10.50 for every $1 invested.The intervention was the implementation of a comprehensive care coordination program.

  Results: Between 1984 and 1995, mean length of stay for children with chronic conditions decreased from 83.9 to 10.6 days; mean annual admissions decreased from 2796 to 1622. Median hospital inpatient charges, adjusted for cost of living, decreased from $26.1 to $14.6 million. A $77.7 million savings occurred for inpatient care, with total expenditures from the insurance program of $3.6 million (a 21:1 ratio). Almost half the professional activities provided for these children were for services that could not be reimbursed in a fee-for-service model. Median adjusted inpatient charges were lower in Rochester, NY ($8,746) than in other academic medical centers ($12,773) or in a national survey of hospitals ($12,462), and fewer children were readmitted within 30 days in Rochester (12.7%) than in other academic medical centers (15.0%).

  Conclusions: An investment of funds by a regional insurance company was associated with reduced costs, admissions, and lengths of stay for children with chronic conditions, and resulted in significant savings for the company. This model may be applicable to other centers. ¹⁰

  References

  1. Thomas F. Tonniges, Judith S. Palfrey, and Maureen Mitchell Introduction S1.1472 2004; 113; 1472- Pediatrics

  2. Cooley WC, McAllister, J. Building Medical Homes: Improvement Strategies in Primary Care for Children With Special Health Care Needs. Pediatrics. 2004; 113(suppl) 1499-1506

  3. Strickland B, McPherson M, Weissma G, van Dyck P, Huang Z, Newacheck, P. Access to the Medical Home: Results of the National Survey of Children With Special Health Care Needs. Pediatrics. 2004:113(suppl): 1485-1492

  4. Sia C, Tonniges T, Osterhus E, Taba S. History of the Medical Home Concept. Pediatrics. 2004; 113 (suppl): 1473-1478

  5. Gupta V, O’Connor K, Quezada-Gomez C. Care Coordination Services in Pediatric Practices Pediatrics.2004;113(suppl):1517-1521

  6. Antonelli R, Antonelli D. Providing a Medical Home: The Cost of Care Coordination Services in a Community-Based, General Pediatric Practice. Pediatrics. 2004;113(suppl):1522-1528

  7. Starfield B, Shi L. The Medical Home, Access to Care, and Insurance: A Review of Evidence. Pediatrics. 2004:113(suppl):1493-1498

  8. Palfrey J, Sofis L, Davidson E, Liu J, Freeman L, Ganz M. The Pediatric Alliance for Coordinated Care: Evaluation of a Medical Home. Pediatrics. 2004:113(suppl):1507-1516.

  9. http://www.medicalhomeinfo.org/resources/state/Downloads/SC/CaseStudy.pdf

  10. Liptak, G., Burns, C., Davidson, P., McAnarney, E. Effects of Providing Comprehensive Ambulatory Services to Children With Chronic Conditions. Archives of Pediatrics and Adolescent Medicine. 1998;152:1003-8

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  The Minnesota Medical Home Project (Minnesota Medical Home Collaborative) is a partnership between The Minnesota Department of Health, the Minnesota Chapter of the American Academy of Pediatrics and PACER Center/Family Voices of Minnesota. The Minnesota Medical Home Learning Collaborative would not be possible without all the pioneering work of the Maternal and Child Health Bureau, the American Academy of Pediatrics, the Center for Medical Home Improvement, and the National Initiative for Children's Healthcare Quality. The Minnesota Project has based its work on the National Medical Home Learning Collaborative, recently finishing one year of work.

  This Project is made possible through a grant from MCHB - Contract Number 1 H02MC00101-3

  The staff person for the Minnesota Medical Home Learning Collaborative is:
     Ann Ricketts, M.S., M.P.H.
     Medical Home Coordinator
     MDH-MCSHN
     P.O. Box 64882
     St. Paul, MN 55164-0882
     651-281-9970
     ann.ricketts@health.state.mn.us

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