Medical Home
What is a Medical Home?

What Your Family Can Do:


Here's what you can do to help your child get the best health care:
 
Write down main questions and concerns to bring to the doctor's attention
Share any changes with your doctor
Celebrate successes and talk about challenges
Meet with office staff who will be working with you and your family
Ask for explanations if you don't understand
Ask for help creating and sharing complete records of your child's care
A Medical Home is:
 
a "home base" for your child's health care needs
a new way of thinking about how your child is cared for
a family-centered approach to healthcare - your opinion matters!
a health care team that looks at the whole child, not just your child's health issues
A medical home is not a building, house, or hospital. It is a way to provide high quality health care services to best meet the needs of your family and children. It is a partnership between you and your family, your primary care doctor, hurse, and clinic staff. Together, we make sure to meet the medical and non-medical needs of your child.
Your Medical Home Team:
Shares information with you and includes you in decisions
Respects your child and family
Provides primary health care including sick and well visits, developmental screening, and immunizations
Works to catch problems early, which can prevent emergency room visits
Helps you plan for and manage any chronic health problems and behavioral health needs
Finds specialists when they are needed
Helps lower family stress, health care costs, missed school and work days

Project & Grant Initiatives


Here are descriptions of some of the Massachusetts Medical Home project and grant initiatives.
 
 
Full list of project and grant initiatives
 
 
 
Early Childhood Comprehensive Systems (ECCS) State Contacts
The Maternal and Child Health Bureau (MCHB) launched the State Maternal and Child Health Early Childhood Comprehensive Systems (ECCS) Initiative to implement the MCHB Strategic Plan for Early Childhood Health. The purpose of ECCS is to support states and communities in their efforts to build and integrate early childhood service systems that address the critical components of access to comprehensive health services and medical homes; social-emotional development and mental health of young children; early care and education; parenting education, and family support. For additional information, you can look up your state's ECCS Grantee Contact or Grantee Web site.
 
​LEND Programs Receive Funding to Improve the Health of Children with Special Health Care Needs
"The Health Resources and Services Administration (HRSA) has awarded $28.3 million to 43 Leadership Education in Neurodevelopmental and Other Related Disabilities (LEND) programs, including the programs at the University of Massachusetts Medical School and the Children's Hospital, to help improve the health of infants, children, adolescents and young adults with neurodevelopmental and other related disabilities, including autism spectrum disorders. LEND programs prepare trainees from a wide variety of professional disciplines to assume leadership roles, ensure high levels of interdisciplinary clinical competence, and enhance the ability of clinicians to diagnose, treat, and manage complex disabilities in youth and adolescents."
 
Medical Home Chapter Champions Program on Asthma, Allergy and Anaphylaxis
 
"Through the support of the Allergy & Asthma Network Mothers of Asthmatics (AANMA), the Medical Home Chapter Champions Program on Asthma, Allergy and Anaphylaxis facilitates the dissemination of best practices, evidence-based guidelines and resources in asthma and allergy care to pediatricians in their states, and supports pediatricians in serving as advocates for change at local, state and national levels. The program seeks to support a successful, national chapter champion network model, initiate a team-based, care coordination and co-management quality improvement learning community; and cultivate an enhanced focus on advocacy and policy."
 
National Center for Children’s Vision and Eye Health
"Prevent Blindness America—the nation’s leading volunteer eye health and safety organization—has established the National Center for Children’s Vision and Eye Health, made possible by a multi-year cooperative agreement from the MCHB. The program is designed to serve as a major resource for the establishment of a public health infrastructure to advance and promote children’s vision and eye care, as well as provide leadership development, health promotion, education, and training to public and private entities throughout the US."


Concurrent Care


Under the Affordable Care Act, children with life-threatening health problems who are enrolled in Medicaid can get both curative treatment and hospice care. This is called concurrent care.
 
What is concurrent care for children?
 
When very sick children qualify for concurrent care, it means they can get 2 different kinds of care at the same time:
 
Curative treatment focuses on curing a health condition. Examples of curative treatment can range from medicine to fight an infection to chemotherapy to fight cancer.
Hospice care (end-of-life care) helps patients who aren't expected to live longer than 6 months stay as comfortable as possible.

What is the Affordable Care Act (ACA)?
 
The ACA is the federal health care reform law signed into law in 2010. (Some people call the law Obamacare.) Most people know that the ACA is about health insurance, but the law also includes many ways to improve health care in the United States.
 
​What changed under the ACA?
 
Before the ACA became law, children with life-threatening health problems couldn't get both curative treatment and hospice care at the same time. For a child to get hospice care, the child's family had to agree to stop all curative treatment first.
 
In many cases this meant that families were forced to choose between treatments that might help their child's life-threatning condition and care that would help their child feel as comfortable and supported as possible at the end of her life. This was often a very painful and difficult choice for patients, families, and doctors.
 
Now, a new rule says that state Medicaid programs have to allow children who qualify for hospice care to get both curative treatment services and hospice care at the same time - if their family and doctors agree it's the right choice for them. This part of the ACA is called Concurrent Care for Children (or Section 2302). 
 
Where can I get more information?
 
Talk with your child's doctors about whether concurrent care is the right choice for your child. To learn more about what your state offers, contact your Medicaid customer service department.
 
You can find more information about caring for children and youth with special health care needs at www.medicalhomeinfo.org 
 
You can find more information about health insurance for children and youth with special health care needs at www.catalystctr.org
 
 
Developed by the National Center for Medical Home Implementation at the American Academy of Pediatrics and the Catalyst
Center at the Boston University School of Public Health through cooperative agreements (U43MC09134; U41MC13618) with the U.S.
Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

Habilitative Services

Heading 1


Do you have a child with a physical or developmental disability, or a
chronic (long-term) health problem?
 
If so, you need to know:
Under the ACA, many health care services that can help your child with the skills your child needs for everyday life (called habilitative services) must be covered by insurance.
What are habilitative services?
 
Habilitative services help people of all ages develop new skills needed for
everyday life. They include things like occupational, physical, or speech
therapy — and hearing and vision services, too. Habilitative services may
also help people build mental, behavioral, or social skills. Certain devices, like
hearing aids, may also be considered habilitative.
 
Habilitative services are very important for children with disabilities who
need help from therapists and other professionals to learn to communicate,
get around, or take care of themselves.
 
What changed under the ACA?
 
Before the ACA became law, many individual and small employer health
insurance plans didn’t cover habilitative services. Now, these services are
included in the ACA as Essential Health Benefits (EHBs), which means that
individual and small group health insurance plans have to cover them.
 
This is a big step forward when it comes to helping children with disabilities
develop the skills they need to grow and learn.
 
What is the Affordable Care Act (ACA)?
 
The ACA is the federal health care reform law signed into law in 2010. (Some people call the law Obamacare.) Most people know that the ACA is about health insurance, but the law also includes many ways to improve health care in the United States. 
 
Are all habilitative services covered by the ACA?
 
No. The law doesn’t say which specific services (or devices) are included.
It’s up to each state to decide the details. This means what’s covered under
habilitative services in one state might be different than what’s covered in
another state.
How do I know if the habilitative services my child needs will be covered under my health plan?
If you already have an individual policy or small employer health plan, call
the customer service phone number for your health plan and ask for a list
of covered habilitative services.
If you’re shopping for a new health plan and need help understanding which
habilitative services are covered, go to localhelp.healthcare.gov. You can
type in your ZIP code or the name of your city or town to find a list of helpful
organizations who can work with you to choose the right plan for your family.
 
You can find another list of consumer assistance resources organized by
state at http://hdwg.org/catalyst/resources. Be sure to think about what
kinds of services your child needs before you choose a plan.
 
Where can I get more information?
 
To find out more about about EHBs like habilitative services, go to
www.healthcare.gov/glossary/essential-health-benefits
 
You can find more information about caring for children and youth with
special health care needs at www.medicalhomeinfo.org
 
You can find more information about health insurance for children and
youth with special health care needs at www.catalystctr.org
 
Developed by the National Center for Medical Home Implementation at the American Academy of Pediatrics and the Catalyst Center at the Boston University School of Public Health through cooperative agreements (U43MC09134; U41MC13618) with the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.
 

Health Home Programs & Coordinated Care

Do you have a child with a chronic (long-term) medical or mental
health problem? Does your child have Medicaid?
 
If you answered yes to both of these questions, you need to know:
Under the ACA, your child may be able to get extra care coordination and support services from your doctor through a Health Home program in your state.
What is care coordination?
Care coordination helps people who need a lot of medical services get the best care possible. When care is coordinated, it means that the families, doctors, and other providers involved in a person’s health care work together as a team.
How can care coordination help my child?
Usually, children who need a lot of health care services have a chronic health problem — these can include behavioral or mental health issues. Your child may get care from different kinds of providers in different places, like hospitals or doctors’ offices. This can make it difficult for you and the different providers to keep track of all the details about your child’s care. It can also cause confusion. For example, 2 different doctors might do the same test because they didn’t know the other had already done it. When doctors and other providers use a coordinated care approach, they talk with each other often, sharing information about your child’s care — and that means better care for your child.
What is the Affordable Care Act (ACA)?
The ACA is the federal health care reform law signed into law in 2010. (Some people call the law Obamacare.) Most people know that the ACA is about health insurance, but the law also includes many ways to improve health care in the United States. Keep in mind that you’re an important part of your child’s care coordination team. Make sure you’re a part of making decisions about your child’s care.
What changed under the ACA?
Since the ACA became law, more doctors and health care providers get paid to talk to each other about their patients. The law allows states to set up a program that pays health care providers to coordinate care for people with chronic illnesses enrolled in Medicaid. This part of the ACA is called Health Homes (or Section 2703).
A few other things to know about state Health Home programs:
States can choose to start a Medicaid Health Home program, but they don’t have to. Health Home programs can be different from state to state. Some states might choose to have a Health Home program for one specific condition — for example, a state could choose to create a program only for people with HIV/AIDS. Health Home programs may also provide patient and family support services, like respite care (short-term child care services), extra help when your child comes home from the hospital, and health education.
How do I know if my child can get coordinated care where we live?
In general, children and youth with Medicaid will qualify for Health Home services if they have:
 
 
2 chronic conditions
1 chronic condition and the risk of developing another one
A serious mental illness

To find out if your state has a Section 2703 Health Home program, contact your state’s Medicaid program member services department. Go to http://www.medicaid.gov and search for “states with health homes.”
Where can I get more information?
To learn more about talking with your doctor about making decisions together for your child, go to www.familyvoices.org
You can find more information about caring for children and youth
with special health care needs at www.medicalhomeinfo.org
You can find more information about health insurance for children
and youth with special health care needs at www.catalystctr.org
 
 
 
Developed by the National Center for Medical Home Implementation at the American Academy of Pediatrics and the Catalyst Center at the Boston University School of Public Health through cooperative agreements (U43MC09134; U41MC13618) with the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

Health Insurance Marketplace & Medicaid Coverage for Children with Disabilities

Building your Care Notebook


The Family Care Notebook is an organizing tool for families and will help you keep track of important information. Care Notebooks are very personal to your child and ideally should be customized to reflect your child's medical history and current information.
 
The National Center for Medical Home Implementation has downloadable forms that you can use to build your own Care Notebook. These tools can help you maintain an ongoing record of your child's:
Care
Services
Providers
Other notes

Your care notebook will help you understand and organize the providers and services that help care for your child and family.
 
Downloadable forms
 
 
 
 
 
Developed by the National Center for Medical Home Implementation at the American Academy of Pediatrics and the Catalyst Center at the Boston University School of Public Health through cooperative agreements (U43MC09134; U41MC13618) with the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.


Do you have a child with a disability? Does your child have individual
or small employer private insurance as primary coverage and
Medicaid as secondary or “wrap-around” coverage?
 
If you answered yes to these questions, you need to know:
Under the ACA you may have the option to choose a new private plan that works better for your family without losing your child’s Medicaid “wrap-around” coverage.
Get the facts:
The ACA set up the Health Insurance Marketplace. When the ACA became a law, it created a new way for people who are unemployed, self-employed, employed part-time or who work for small businesses to get health insurance. It’s called the Health Insurance Marketplace. The Health Insurance Marketplace helps Americans find and enroll in the individual or small employer health insurance coverage they need at prices they can afford. You can get to the Marketplace through a website, a toll-free call center, or through in-person help. 
 
By filling out one application, the Health Insurance Marketplace can tell you if you qualify for:
 
Private insurance, including financial help based on how much money your family makes 
Medicaid or the Children’s Health Insurance Program (CHIP).

What is the Affordable Care Act (ACA)?
The ACA is the federal health care reform law signed into law in 2010. (Some people call the law Obamacare.) Most people know that the ACA is about health insurance, but the law also includes many ways to improve health care in the United States. Everyone needs Minimum Essential Coverage (MEC). One part of the ACA says that every American has to have health insurance that meets a certain standard for benefits and affordability. Health insurance that meets this standard is called Minimum Essential Coverage (MEC).
 
Types of insurance that are considered MEC include:
 
Private insurance, like a plan you get through your job or a policy you buy as an individual
Insurance plans you buy through the Health Insurance Marketplace
Public benefit programs like Medicaid, Medicare, and the Children’s Health Insurance Program (CHIP)

Your family can still qualify for a new plan from the Marketplace.
If your employer does not offer family coverage, if you’re self-employed, if you work part-time, for a small business or you are not employed, you may still qualify for coverage and any financial help you and your family members who do not have MEC coverage may be eligible for. Your family can shop for a new plan — and your child with a disability won’t have to lose their Medicaid wrap coverage. Because your child with a disability already has MEC coverage through Medicaid, your child won’t qualify for financial help through
a Marketplace plan — but other members of your family might. Premiums for coverage will be based on everyone enrolling in the Marketplace plan. Financial help will be based on those without MEC coverage.
Choosing a health plan can be a complicated decision, especially if you have a family member with a disability or special health care needs. If you need help understanding your options, go to localhelp.healthcare.gov. You can type in your ZIP code or the name of your city or town to find a list of helpful organizations who can work with you to choose the right plan. Another list of consumer assistance resources organized by state is located at hdwg.org/catalyst/resources. 
To learn more about the Health Insurance Marketplace, go to www.healthcare.gov
 
You can find more information about caring for children and youth with special health care needs at www.medicalhomeinfo.org
 
You can find more information about health insurance for children and youth with special health care needs at www.catalystctr.org
 
Developed by the National Center for Medical Home Implementation at the American Academy of Pediatrics and the Catalyst Center at the Boston University School of Public Health through cooperative agreements (U43MC09134; U41MC13618) with the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

Community and state resources


2-1-1
"2-1-1 is a free and confidential service that helps people across North America find the local resources they need. We're here for you 24 hours a day, seven days a week."
 
Family Voices
 
"Family Voices is a national, nonprofit, family-led organization promoting quality health care for all children and youth, particularly those with special health care needs. Working with family leaders and professional partners at the local, state, regional, and national levels since 1992, Family Voices has brought a respected family perspective to improving health care programs and policies and ensuring that health care systems include, listen to, and honor the voices of families."
 
National Parent Helpline
 
"Being a parent is a critically important job, 24 hours a day. It’s not always easy. Call the National Parent Helpline® to get emotional support from a trained Advocate and become empowered and a stronger parent."
 
Substance Abuse and Mental Health Services Administration
 
"The Behavioral Health Treatment Services Locator is an online source of information for persons seeking treatment facilities in the United States or U.S. Territories for substance abuse/addiction and/or mental health problems."
 
 
Text4baby
"Join the hundreds of thousands of moms who receive free text messages throughout their pregnancy and their baby’s first year."