Resources

Evaluation Tools

A great place to start in determining where to direct resources for practice improvement is an assessment of how well the practice is functioning as a medical home. There are many evaluation tools available to help with this assessment. While some tools assess all 7 key components of well-functioning medical homes, many tools focus on a particular aspect of medical home provision, such as family centered care or culturally sensitive care.

Some practices use general medical home evaluation tools to stimulate conversation during their SWOT analysis or to incorporate opinions of various stakeholders, such as patients and parents, into their initial discussions. After your practice performs a SWOT analysis (see Strategic Planning), you will have a better idea of which themes of medical home development fit the most pressing needs of your patient population, and you can use this as a guide to selecting a more specific tool.

Table 1 provides a listing of many available tools and areas of medical home evaluation.

Table 2 provides a listing of the tools, areas of focus, an time required to complete.

Table 3 provides contact information for downloading tools or requesting permission for use.

A good resource for investigating tools is the Measuring Medical Homes resource, which discussed the development and application of each tool.

Toolkits and Forms

Care Coordination

Medical Home Practice-Based Care Coordination: A Workbook By: Jeanne W. McAllister Elizabeth Presler W. Carl Cooley. Center for Medical Home Improvement (CMHI) Crotched Mountain Foundation & Rehabilitation Center; Greenfield, New Hampshire

This toolkit provides simple how-to instructions for basic care coordination functions in the medical home. It includes: care coordination checklists, job descriptions for care coordination in the medical home, tips for implementation, and a Care Coordination PDSA template

Chronic Illness

Integrating Chronic Care and Business Strategies in the Safety Net. Prepared for Agency for Healthcare Research and Quality U.S. Department of Health and Human Services. AHRQ Publication NO. 08-0104-E. August 2008.

This extensive resource was designed mainly for adult providers, but most of the content can be extrapolated to pediatrics. It includes:

  • Strategic Planning materials, including leadership preparation, PDSA templates, and information on change management
  • Pay for Performance guide
  • Group Visit Guide/Templates
  • Template for Huddles
  • Billing guides
  • Links for some disease management templates

The Physician's Guide to Caring for Children with Disabilities and Chronic Conditions, Nickel & Desch, copyright © 2000 by Paul H. Brookes Publishing Co.

This resource is downloadable by anyone purchasing the above publication. This download includes hundreds of pages of visit and screening templates. Some resources are as follows:

  • Health Information Questionnaire for Children in Early Intervention Systems
  • Family Risk Assessment
  • Family Assessments during acute and chronic illness
  • Family Assessment for Primary Care
  • Assessment of Family Impact of Chronic Illnesses
  • Links for some disease management templates
  • Diet Recall Template
  • Family and Physician Management Templates for Children and Youth with Developmental Delay and Mental Retardation, Down Syndrome, Cerebral Palsy (exam form), ADHD, Autism and pervasive developmental delay, visual impairments, anxiety, prenatal drug exposure, HIV, Meningomyelocoele and related disorders, Craniofacial disorders, Traumatic Brain Injury, Spinal Cord Injury, Seizure Disorder, and Cystic Fibrosis.

Developmental and Behavioral Screening and Diagnosis

The Tennessee Chapter of the American Academy of Pediatrics hosts a wealth of online and community training resources. The START module specifically addresses developmental and behavioral screening and diagnosis in the primary care setting.

START is an educational program developed by TNAAP to help pediatric care providers - including pediatricians, family physicians, physician assistants, nurse practitioners, nurses, and others - learn skills and strategies to implement routine developmental screening using standardized screening tools as part of their health care procedures. It was adapted with permission from the Illinois Chapter of the American Academy of Pediatrics (ICAAP). The program is collaboration with Tennessee's Early Intervention System (TEIS) funded by the Tennessee Department of Education. 

Mental Health

The Tennessee Chapter of the American Academy of Pediatrics hosts a wealth of online and community training resources. The Tennessee Chapter of the American Academy of Pediatrics has partnered with BlueCare to develop the Behaviorally Effective Healthcare in Pediatrics (BEHIP) training program.

BEHIP training provides pediatric healthcare providers with tools and strategies to screen for, assess, and manage patients with emotional, behavioral and substance abuse issues. It also encompasses strategies to provide for more efficient workflow (including information on coding), more effective care, and improved family and physician relationships.

Helpful forms included in this training include:

Guidelines for Adolescent Depression in Primary Care. GLAD PC Tool Kit. Version 1, 2007.

This toolkit is designed to guide depression treatment by primary care practitioners in the primary care setting. It includes the following:

  • Practitioner flow diagrams for diagnosis and treatment
  • Screening Tools
  • Diagnostic Tools
  • Indications for active monitoring, psychotherapy, and pharmacotherapy
  • Pharmacotherapy guide
  • Template for side effect monitoring
  • Template for release of protected health information
  • Template for mental health provider correspondence
  • Family discussion and anticipatory guidance
  • Billing and Documentation Information
  • Guide to changing Depression Treatment Processes using the PDSA cycle

Obesity

The Tennessee Chapter of the American Academy of Pediatrics hosts a wealth of online and community training resources. The Healthy Eating and Living Education (HEALED) program provides regional and in-office training to primary care physicians for the prevention, evaluation, management and treatment of childhood obesity in the primary care setting.

Strategic Planning

Building Your Medical Home Toolkit. American Academy of Pediatrics.

This is the official medical home support tool of the AAP, which contains extensive information on general medical home development. Education is presented in a variety of modalities with the ability of a practice to monitor its progress. A variety of helpful forms are provided in English and Spanish. Some helpful forms are as follows:

Helpful forms included in this training include:

  • Emergency Information for CSHCN
  • Action Plan
  • Pediatric Care Plan

Integrating Chronic Care and Business Strategies in the Safety Net. Prepared for Agency for Healthcare Research and Quality U.S. Department of Health and Human Services. AHRQ Publication NO. 08-0104-E. August 2008.

This extensive resource was designed mainly for adult providers, but most of the content can be extrapolated to pediatrics. It includes:

  • Strategic Planning materials, including leadership preparation, PDSA templates, and information on change management
  • Pay for Performance guide
  • Group Visit Guide/Templates
  • Template for Huddles
  • Billing guides
  • Links for some disease management templates

Comprehensive Care Planning. Medical Home Learning Collaborative. Center for Medical Home Improvement and National Institute for Children's Healthcare Quality.

This resource provides a wealth of excellent paper-format forms for CYSHCN, including:

  • Child Medical Summary
  • Child Medical Care Plan
  • Chronic Condition Management
  • Pediatric Care Plan
  • Child History Fact Sheet
  • Emergency Information for CYSHCN
Tennessee Chapter American Academy of Pediatrics