Medical Homes and Neighborhoods
for Children with Special Health Care Needs
Developmental-Behavioral Pediatrics Rotation
Kate Orville, MPH, Co-Director, Washington State Medical Home Partnerships Project
UW Center on Human Development and Disability,
orville@uw.edu, 206-685-1279 www.medicalhome.org
1. Introductions
Name, year of training, Continuity Clinic, interests, plans for future, questions about serving children
with special needs, familiarity with medical home…
Medical Home Partnerships Project
2. Health Care Now and Medical Home Initiatives
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What’s working in health care now and what isn’t?
Children with special health care needs – at least 15% of kids- what are the particular gaps for
them you see?
Children with special health care needs are those who have or are at risk for a
chronic physical, developmental, behavioral, or emotional condition and who
also require health and related services of a type or amount beyond that
required by children generally. -- US Maternal and Child Health Bureau,
endorsed by AAP
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Medical Home and Quality Improvement Initiatives: From a medical home for children with
special health care needs to medical/health homes for all!
From the Patient-Centered Primary Care Collaborative (PCPCC) (www.pcpcc.net)
“The medical home is best described as a model or philosophy of primary care that is patientcentered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety.
It has become a widely accepted model for how primary care should be organized and delivered
throughout the health care system, and is a philosophy of health care delivery that encourages
providers and care teams to meet patients where they are, from the most simple to the most
complex conditions. It is a place where patients are treated with respect, dignity, and compassion,
and enable strong and trusting relationships with providers and staff. Above all, the medical home is
not a final destination instead, it is a model for achieving primary care excellence so that care is
received in the right place, at the right time, and in the manner that best suits a patient's needs.
Pediatric Resident Medical Home & Community Resources Inservice 12/13 p. 1
In 2007, the major primary care physician associations developed and endorsed the Joint Principles of
the Patient-Centered Medical Home. The model has since evolved, and today the PCPCC actively
promotes the medical home as defined by the Agency for Healthcare Research and Quality (AHRQ).
For Health Care Professionals and Clinics:
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Patient-Centered Medical Home: What you Need to Know
http://www.pcpcc.net/sites/default/files/resources/12_MI394900MHC_401_01_GD.pdf
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Infographic: Why the Medical Home Works: A Framework (March 2013)
The PCPCC has developed a framework to help medical home supporters and advocates
explain the benefits and strategies associated with delivering patient-centered primary
care. The graphic is organized according to the five key features of the medical home
model: Patient-centered, comprehensive, coordinated, accessible, and committed to
quality and safety.
www.pcpcc.net/resource/infographic-why-medical-home-works
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WA State Medical Home Key Messages:
www.medicalhome.org/4Download/keymessages2007.pdf
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What do you think? Concerns? Right Direction?
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How do you measure and reward medical homes?
Patient/Family Surveys (example of: National Survey of Children with Special Health Care
Needs (NS-CSHCN) 2009/10 data for WA at:
http://www.childhealthdata.org/docs/medical-home/2009-10-mhreports_wa-748.pdf
Interactive data set: http://www.childhealthdata.org/browse/snapshots/medical-homeprofiles-cshcn
Recognition/Accreditation Programs
 National Committee for Quality Assurance Patient-Centered Medical Home Recognition
 The Joint Commission Primary Care Medical Home Accreditation Program
 Accreditation Association for Ambulatory Health Care: Medical Home Certification or
Accreditation:
 URAC (formerly known as the Utilization Review Accreditation Commission) Patient
Centered Health Care Home Program
Institute for Healthcare Improvement (IHI):
 The Institute for Healthcare Improvement offers a program called Open School which
includes a very well respected online curriculum on leadership and quality improvement.
It is free for health care students enrolled in universities with a medical school.
www.ihi.org/offerings/IHIOpenSchool/Pages/default.aspx
 The UW has a local chapter of the Institute for Healthcare Improvement run by health
care students website
Pediatric Resident Medical Home & Community Resources Inservice 12/13 p. 2
NOTE: More information about Medical Home and QI efforts in WA available in Medical Home
Partnerships Project Fall 2012 newsletter:
http://www.medicalhome.org/4Download/Newsletter/MHLN%20_e-update%20_Fall_2012.pdf

Medical Home and Residency Programs:
Handing Off Primary Care Patients at the End of a Pediatric Residency
Juniper Lyra Burch. Pediatrics 2013;132;985; originally published online November
18, 2013; DOI: 10.1542/peds.2013-1676
http://pediatrics.aappublications.org/content/132/6/985.full.pdf
Pediatric Medical Home Program at UCLA:
http://newsroom.ucla.edu/portal/ucla/study-shows-pediatric-residency-154162.aspx
http://www.uclahealth.org/body_mattel.cfm?id=1434
National Center for Medical Home Implementation (AAP)
Resources for Educating Residents on Medical Home:
http://www.medicalhomeinfo.org/training/residency.aspx
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Medical Home Neighborhood
http://www.acponline.org/running_practice/delivery_and_payment_models/pcmh/understa
nding/specialty_physicians.htm
o
o
o
A checklist of recommended information to include on a referral request from a PCMH
to a subspecialty/specialty
PCMH-Neighbor
A checklist of recommended information to include on a response from a PCMHNeighbor to a referring PCMH practice
A set of general care coordination/service agreements (compacts) between a PCMH and
PCMH-N practice
Frequently Asked Questions About the Relationship of the PCMH to Specialty Physicians
(2009)
Pediatric Resident Medical Home & Community Resources Inservice 12/13 p. 3
3. Community Resources
Medical Home as a Team Sport -who’s available in the community to support your and patients?
(most information available at: http://www.medicalhome.org/resources/local_contacts.cfm )
Quick Key Contacts on the Medical Home Partnerships Website:
http://www.medicalhome.org/resources/local_contacts.cfm
WithinReach
 Family Health Hotline The Dept of Health CSHCN program supports the WithinReach
toll-free information line (1-800 322-2588 or 1-800-883-6388/TTY). Information &
Referral Specialists who answer the calls provide local and state resource information for
Washington families with children with special health care needs on health care
coverage, specialty services, recreational opportunities, and more.
 ParentHelp123 www.parenthelp123.org
Public Health: County Children with Special Health Care Needs Coordinator (0-18)
King County: Donna Borgford-Parnell, RN, 206-296-4610
www.kingcounty.gov/healthservices/health/child/~/media/health/publichealth/
documents/cshcn/CSHCNCoordinators.ashx
Early Intervention Family Resources Coordinator (0-3) and the Early Support for Infants and Toddlers
Program
King County: Nona Chitwood, Lead FRC, Community Health Access Program 800-756-5437 or
206-284-0331
http://del.wa.gov/publications/esit/docs/ContactsDirectory.pdf
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ESIT program letter: “Dear Primary Care Provider”
http://del.wa.gov/publications/esit/docs/DearWAPrimaryCaregiver.pdf
Early Intervention Eligibility: http://del.wa.gov/development/esit/eligibility.aspx
Information for Families about EI: http://del.wa.gov/development/esit/families.aspx
Pediatric Resident Medical Home & Community Resources Inservice 12/13 p. 4
Schools- (36 months- 21 years) Special Education
http://www.k12.wa.us/SpecialEd/Families/default.aspx
Special education is specially designed instruction that addresses the unique needs of a
student eligible to receive special education services. Special education is provided at no cost
to parents and includes the related services a student needs to access her/his educational
program.
The request for testing to determine if a child qualifies to receive special education must be
made in writing. It is a good idea to direct the request both to a district staff member at the
building level (school psychologist or special education teacher) and to your district’s special
education director at the administrative level.
 Statewide directory of school officials:
www.k12.wa.us/SpecialEd/pubdocs/SpecialEdDirectory.pdf
 Seattle District Director of Special Education. 206-252-0055
 Info about accessing special ed services in Seattle:
http://www.seattleschools.org/modules/cms/pages.phtml?sessionid=3706345d0fe8ae9b5e9aa7f29b31eba6
&pageid=224928&sessionid=3706345d0fe8ae9b5e9aa7f29b31eba6
IDEA vs. Section 504
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The Individuals with Disabilities Education Act (IDEA) of 2004 is the federal law that
guarantees a free appropriate public education (FAPE) is provided to students with
disabilities.
Section 504 of the Rehabilitation Act of 1973 is a federal civil rights law which prohibits
discrimination against individuals with disabilities. Section 504 ensures that students with
disabilities have equal access to educational programs, services, and activities. The IDEA is
a special education law. Section 504 is different from IDEA in that it does not provide for
specially designed instruction or require creating an Individualized Education Plan (IEP).
Problems with a School System?
Office of the Education Ombuds (OEO) http://www.governor.wa.gov/oeo/
OEO resolves complaints, disputes, and problems between families and
Washington State elementary and secondary public schools in all areas that
affect student learning. OEO is a statewide agency that functions independently
from the public school system. Our services are free, confidential and available
to families and students from Kindergarten to 12th grade. Open 8 a.m. – 5 pm.
Request OEO services by calling: 1-866-297-2597
Phone interpreter services available: Office phone: 206-748-5613
Office of the Superintendent for Public Instruction, Special Education Ombuds
Kristin Hennessey 360-725-6075 kristin.hennessey@k12.wa.us
http://www.governor.wa.gov/oeo/education/specialed.asp
Or Family Support Organizations The ARC of WA/Parent to Parent or PAVE
Pediatric Resident Medical Home & Community Resources Inservice 12/13 p. 5
Family Support Organizations (Parent to Parent, Fathers Network, Diagnosis specific groups etc)
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Parent to Parent - Statewide parent network providing emotional support
and information to parents who have children with disabilities or
developmental delays. 1-800-821-5927
http://arcwa.org/getsupport/parent_to_parent_p2p_programs
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Fathers Network - Advocates for and provides support and resources for all
men and families who have children with special needs.
www.fathersnetwork.org
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PAVE (Partnerships for Action Voices for Empowerment) - Statewide parent
training and information center providing assistance to families who children
with disabilities, ages birth through adulthood. 1-800-5 PARENT
www.washingtonpave.org
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National Alliance for the Mentally Ill (NAMI) - WA State and Local Chapters provide support, education, information and referral and advocacy for
consumers, families, and friends of people with severe mental illnesses, such
as schizophrenia, schizoaffective disorder, bipolar disorder, major depressive
disorder, obsessive-compulsive disorder, panic and other severe anxiety
disorders, autism and pervasive developmental disorders, attention
deficit/hyperactivity disorder, and other severe and persistent mental
illnesses that affect the brain.
www.nami.org/Template.cfm?section=your_local_NAMI
More organizations: http://www.medicalhome.org/resources/spd_se_fs.cfm
Pediatric Resident Medical Home & Community Resources Inservice 12/13 p. 6
Managed Care organizations – Care Coordinators
Medicaid/Apple Health Managed Care plans have care coordination services that can be very helpful
for children and other individuals with special health care needs. Representatives from these plans
attend the quarterly Children with Special Health Care Needs state meetings and have provided
information about their services. The representatives report that the services and processes used are
similar from plan to plan.
COORDINATED CARE
www.coordinatedcarehealth.com Coverage Area: See website

Elizabeth Allen, 877-644-4613, ext. 69728 ELALLEN@coordinatedcarehealth.com
Questions had been supplied to health plans prior to the CSHCN Communication Network Meeting.
The following are answers from Coordinated Care.
What criteria are used to identify children with special health care needs enrolled in your
plan? There are several ways children with special health care needs are identified. We have a
sophisticated computer program that analyzes information about each child and assesses
potential level of need. We also receive referrals from a variety of sources including parents,
pediatricians, clinics, hospitals, case managers or case workers, physical therapists,
occupational therapists, speech therapists and support systems involved with the child with
special needs. We identify Children with Special Health Care Needs via ER usage reports,
number of times a child has been hospitalized and reports focused on various special health
care needs diagnoses for children. All this information is reviewed by health care professionals
and
Children with Special Health Care Needs are given the highest priority for outreach by our
Case Management Team.
What is your role with children with special health care needs enrolled in your plan and their
families? Coordinated Care provides complex case management and care coordination
services to Children with Special Health Care Needs and their families. Our Nurse Case
Managers provide coordination across the continuum of care for Children with Special Health
Care Needs. We also attend to the needs of mothers with high risk pregnancies. Our Social
Workers help families network and navigate the health care system while providing
psychosocial support. We have behavioral health specialists who also provide services to
children with special health care needs. We focus on empowering the families of Children with
Special Health Care Needs to advocate for themselves.
How would someone outside of your plan learn what services, treatments, devices, etc. are
covered by your plan, at what rate, and if Prior Authorization is required?
We provide a toll free line, 1-877-644-4613, where anyone can speak to our Member Services
Representatives who are able to explain all benefits and coverage answering any questions a
parent
may have. We also have a very user friendly website for members and providers,
http://www.coordinatedcarehealth.com available online, identifying what necessitates Prior
Pediatric Resident Medical Home & Community Resources Inservice 12/13 p. 7
Authorization. In addition, our plan provides community outreach and education through
various events including health fairs and conferences. We have Provider Relations Specialists
who provide education regarding Health Plan benefits. The Healthy Options Booklet available
from DSHS explains our benefits and has our contact information.
Please add any other plan updates that may be of interest to meeting participants who work
with children with special health care needs and their families.
Coordinated Care Health Plan has a Foster Care Program for Children with Special
Health Care Needs, a Neonatal Intensive Care Unit Program for premature and/or ill infants, a
Start Smart for Baby Program to support all expecting mothers including those with high risk
pregnancies and a SSI Conversion Program to assist members in applying for SSI benefits for
their children.
COMMUNITY HEALTH PLAN OF WA
www.chpw.org - Coverage Area Includes All Counties except Clallam, Columbia, Garfield,
Jefferson, Klickitat, Lincoln, Mason, Skamania and Whitman

Stacy Heinle, 206-613-8894 Stacy.Heinle@chpw.org

Sue Collins, 206-652-7124 sue.collins@chpw.org
UNITED HEALTHCARE
www.uhc.com Coverage Area: See website

Cindy Spain, 206-749-4347 cindy_l_spain@uhc.com
AMERIGROUP
www.amerigroupcorp.com Coverage Area: See website
 Lani Spencer, 206-674-4470 Lani.Spencer@amerigroup.com
Lani Spencer reported that all plans are similar in their processes as Coordinated Care. All
contractually do the same. The Centralized Case Manager phone number is 855-323-4688. If caller
has specific needs the receptionist will transfer to appropriate case manager.
MOLINA
www.molinahealthcare.com Coverage Area Includes All Counties except Clark, Island,
Jefferson, Klickitat, Skamania, and Wahkiakum ]


Cathi Sears, Molina Healthcare of Washington 800-869-7175,ext. 147148 (covers West side of
WA)
catherine.sears@molinahealthcare.com
Nikki Nordstrom, Molina Healthcare of Washington 800-869-7175, ext. 147141 (covers East
side of WA)
nikki.nordstrom@molinahealthcare.com
See Molina handout on “Understanding Molina Healthcare Services.”
Pediatric Resident Medical Home & Community Resources Inservice 12/13 p. 8
4. Practice Tools
Care Organizers:
 Build a Care Notebook: http://cshcn.org/planning-record-keeping/care-notebook
 Order a Care Organizer: http://cshcn.org/planning-record-keeping/care-organizer
Care Plans:
 Emergency care plans
o www.aap.org/advocacy/emergprep.htm (AAP and Emergency MDs)
o http://cshcn.org/planning-record-keeping/care-plans-parents/parents-create-careplan
 Medical Care plans:
o http://www.medicalhomeinfo.org/how/care_delivery/#care

Other Care plans: helps everyone interacting with the child to understand basic information
about the child
o http://cshcn.org/planning-record-keeping/care-plans-parents
Article: Adams et al. “Exploring the usefulness of comprehensive care plans for children with
medical complexity (CMC): a qualitative study”. BMC Pediatrics 2013, 13:10
http://www.biomedcentral.com/1471-2431/13/10 or
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3570291/
Written information about the diagnosis or condition
o Examples: www.healthychildren.org, www.medlineplus.gov, www.kidshealth.org (for
parents, kids and teens)
Medical Home Implementation websites
 AAP: Building Your Medical Home Toolkit: http://www.pediatricmedhome.org/
 National Center for Medical Home Initiatives www.medicalhomeinfo.org
 WA State Medical Home Partnerships www.medicalhome.org
 WA State Dept of Health – WA Healthcare Improvement Network
http://www.doh.wa.gov/PublicHealthandHealthcareProviders/HealthcareProfessionsand
Facilities/ProfessionalResources/WashingtonHealthcareImprovementNetwork.aspx
5. Discussion
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How does this description of medical homes reflect your experience?
What seems like it might be useful to you in practice?
What information was most helpful to you today?
What is something you might do differently as a result of discussion today?
What would you like to know more about?
Advice for future inservices for trainees?
Pediatric Resident Medical Home & Community Resources Inservice 12/13 p. 9