What is a Medical Home?

A Medical Home is quality, community based primary care for adults, youth and children with special health care needs and/or disabilities that is based on a trusting and respectful relationship between the primary care provider and the patient and the patient's family.

A Medical Home respects and values the unique information and experience patients have about themselves and families have about their child that no one else brings to the team.

A great Medical Home:

  • Knows it's patients
  • Partners with and learns from patients/youth and families
  • Uses a team approach to chronic care management
  • Coordinates all aspects of care
  • Co-management with patients/families and specialists
  • Assistance with transitions
  • Connections with community organizations and resources
  • Is satisfying for patients, families, providers and clinic staff

You can be proactive in creating your own Medical Home

 Choosing a Health Care Provider

1. Check with your insurance provider to get a list of primary providers in your area. 

2. Look for a provider whose style and office procedures
fit your needs. Talk with family, friends and other providers you work with about providers they recommend.  

3. Set up an appointment to meet with the primary provider, so you can discuss with him/her what you are looking for and learn more about how their clinic and practice works.

4. Do you think the provider's style and clinic fits your needs and those of you and/or your child?

5.  How do partners in the practice communicate the needs of patients with chronic conditions so that if you/your child needs care after hours or on weekends you can work with someone who will understand you/your child's unique needs?

6. Can you talk easily with this provider? Is your language and culture understood and respected?

7. Choose a primary doctor who will: provide well care; sick care; help you coordinate you/your child's chronic care needs, and see you as a partner in decisions about you/your child's care

8. Ask the doctor to help develop a care plan for your child. A care plan is a great tool that can help you and all your child's doctors, nurses, school staff and others understand your child's needs and communicate better.

9. Be an active partner in your child's care: Write down questions, concerns and observations about your child to share with the doctor.

10. Think about your family's goals for your child and talk about them with the doctor so your goals can help guide the care.

1.  A care plan or summary is a document that summarizes:

     a. all of your chronic health conditions

     b. the status of those conditions

     b. medications

     c. physicians and other providers you work with

     d. equipment you use

     e. important health events

     f.  preferences you have for your care

     g. typical protocols for treatments

     h. normal/typical findings, eg. lab work, x-rays

This type of health summary can assit you in communicating your needs to all providers and can be used as a health plan for school.

For more information check out the following links:

The American Academy of Pediatrics promotes and supports Medical Home across the country and has many helpful resources for families and physicians through the National Center for Medical Home: www.medicalhomeinfo.org

The Center for Medical Home Improvement offers great information and resources for providers and parents to create a medical home:  www.medicalhomeimprovement.org

The Institute for Family-Centered Care offers many resources, tools and information about patient/family-centered care:  www.familycenteredcare.org

Parents - you can create and maintain a detailed, internet based record of your child's important medical information for free using Children's Medical Organizer: www.childrenshc.org/cmo/index.asp

What do parents on the Medical Home teams say about Medical Home?

"We have a care plan that is always with us, and the hospital and clinic are aware of her special health needs and openly give Miriam that much needed extra time and gentleness. All these little changes are making a significant difference not only for Miriam but for our family".           Miriam's Mom

About Personal Health Records / Care Notebooks

A Care Notebook is an organizing tool for families who have children with special health care needs. Use a Care Notebook to keep track of important information about your child’s health and care. Keeping your own personal health record (PHR) allows you to provide doctors with valuable information that can help improve the quality of care you receive. A PHR can help reduce or eliminate duplicate tests and allow you to receive faster, safer treatment and care in an emergency. In short, a PHR helps you play a more active role in yours and your loved ones’ healthcare.

Types of Personal Health Records / Care Notebooks

  • You can simply gather your information and place it in a file folder.
  • You can transfer the information to a computer disk, and carry that with you.
  • Portable devices are available that allow you to carry the information on a chip inside something called a USB drive, that plugs into most computers.
  • Internet-based services offer secure servers that you access from a computer and on which you enter your information. Some of these are free, and for others you may have to pay a fee or subscription.

Getting Started

The following are some links to helpful resources to figure out how to pull together your own PHR or Care Notebook.

Personal Health Records / Care Notebooks

Downloads - Templates & Forms

Center for Medical Home Improvement
CMHI promotes the medical home as a family-centered “way of doing things” for CSHCN; this includes how practices partner with, respond to, and care for children, especially those with or at risk for developing special health care needs. CHMI makes the following sample plans available:

Other downloads from Center for Medical Home Improvement

The National Center for Medical Home Initiatives

Integrated Services Care Plan: pdf PDF | MS Word Version MS Word
A comprehensive assessment that includes: demographics, current problems with status, routine health maintenance, specialty care, medical support services, hospital care, education, rehab services, pharmacy needs, medical equipment/home care, community services, and a parent/caregiver signature page. Developed by the PA Medical Home Program - EPIC IC.

Emergency Preparedness for Children with Special Health Care Needs
To facilitate prompt and appropriate emergency care for children with special health care needs, the American Academy of Pediatrics (AAP) and the American College of Emergency Physicians (ACEP) have developed an Emergency Information Form and other materials which can be used as a tool to transfer critical information about these children. It is hoped that the form will gain acceptance and be utilized by primary caregivers and specialists so that emergency physicians may have access to vital information when emergencies occur.

  • Blank Emergency Information Form pdf PDF |
  • Blank Interactive Emergency Information Form MS Word Version MS Word |
  • Sample Emergency Information Form pdf PDF |
  • Sample Emergency Information Form in Spanish pdf PDF |
  • Instructions for Parents on Using the Form Website Website |

  • Wisconsin Emergency Medical Service for Children (EMSC) Website Website |
    The Emergency Medical Services for Children (EMSC) Program is a national initiative administered by the USDHSS  Health Resource Services Administration in partnership with the US Department of Transportation's National Highway Traffic Safety Administration. The Wisconsin EMSC program partners with the Wisconsin Emergency Medical System Program  and the State Trauma Care Advisory Council to ensure that state of the art pediatric emergency medical services are integrated into the overall EMS system, and are accessible to all children. 

 

MyPHR Forms - Adult Forms
This fifteen-page form contains space for recording: Allergies, Identification, Medical history, Major illness/operations, Medications, Infectious diseases, Immunizations, Health maintenance, Devices and prostheses, Eye information, Healthcare documents, and Family medical history.

Child Form
This five-page form contains space for recording: Allergies, Identification, Birth date, Growth and development, Immunizations, Medications, and Infectious diseases.

  • English Version for Children: pdf PDF | MS Word Version Word
  • Spanish Version for Children: pdf PDF | MS Word Version Word

Health Forms and Records by Dr. Marie Savard

Dr. Savard's Forms (Link takes you to another page on this CD)
Dr. Savard is Author of How to Save Your Own Life: The Savard System for Managing--and Controlling--Your Health Care and The Savard Health Record.

My Family Health Portrait
U.S. Surgeon General's Family History Initiative

Care Notebook - Washington
The Care Notebook and Care Organizer are tools for families who have children with special health care needs developed in Washington State Children's Hospital and Regional Center. Families use Care Notebooks to keep track of important information about their child's health and care. This makes it easier to find and share key information with their child's care team. These tools are available in English, Spanish, Russian, and Vietnamese.

Family Information Notebook (FIN)
The Family Information Notebook (FIN) was developed at Children's Hospital at Vanderbilt. The notebook is designed to help families coordinate many aspects of their child's care and health. It can help families and others caring for a child exchange information so the child's special health care needs can be met appropriately. Families may share copies of any part of their notebook with anyone who works with their child, including family members and friends.

Vital Records Guide PDF pdf |
The Vital Records Guide gives parents an easy way to record the information they need to deal with physicians,
hospital records personnel, therapists, insurance firms, federal, state and local agencies and organizations, direct support
professionals and all other professional and personal support personnel needed provide the appropriate care for a
child with a disability or chronic illness. Pages from the printed guide can be easily copied. From the Arkansas Governor’s Developmental Disabilities Council.

My Child's Life Care Notebook and Organizer
The "My Child's Life Care Notebook and Organizer" is offered free to parents of children with disabilities. This organizer was developed to help families record and track the day-to-day needs of children with disabilities. From the Jean Baton Swindells Resource Center for Children and Families at Providence Medford Medical Center in Oregon.

  • English Version PDF pdf |
  • Russian Language Version PDF pdf |
  • Este recurso esta disponible en un versión de español también: PDF pdf |
    “Mi cuaderno de notas y organizador del cuidado vital de mi hijo(a).”

The Maine Health Care Notebook PDF pdf | MS Word MS Word |
The Maine Care Notebook is a health care notebook will help you keep information organized in a central location. Developing a health care notebook for your child will also make it easier for you to share information with others who are part of your child's care team.

Child’s Personal and Portable Health Record
From the Alameda County Medical Home Project, adapted from the Southwest Institute for Families of Children with Special Needs
Child Health Status Assessment

  • English Version PDF pdf |
  • Spanish Language Version PDF pdf |

Utah Care Notebook PDF pdf |
This Care Notebook is an organizing tool for families who have children with special health care needs. Utah created the book to help families keep track of important health care information, list providers and community organizations contact information, prepare for appointments and file and share health history. Utah Family Voices shared this guide so that other resource centers may use this as a template when developing similar tools.

Build Your Own Care Notebook
http://www.medicalhomeinfo.org/CareNoteBook/ Website
Extensive list of sample plans to download from the National Center of Medical Home Initiatives from the American Academy of Pediatrics. Organized by topic area.

Other Templates: