Children and Youth with Special Health Needs (CYSHN)
Medical Home Team Spotlights
Duluth Children's Clinic Medical Home Team
Medical Home Accomplishments 
- Care Plan
- Working with Peds Neuro to include Seizure Emergency Care Plan
- Meeting with Peds Neurology
- Dr. Harvieux and Dr. Kanoff will be shadowing each other to better improve communication between departments/quality improvement
- Charts tagged in EPIC using Permanent Comments, FYI and/or Diagnosis
- MH Bulletin Board
- Spring Focus Group
- Evening informational meeting to better introduce the concept of Medical Home to families of CSHCNs
- Autism Parent Support Group
- Helped co-found
- Supported the local ADHD group
- Developmental Screening Meeting
- The Medical Home team
- Duluth Children’s Pediatrics
- Early Childhood screeners from the surrounding counties
- Discussed referrals, evaluations and follow up
- Establish a registry in EPIC of MH patients
- Main patient list
- Additional lists by diagnosis
- Private Phone Line into Dept. for MH patients
- Previsit Phone Call
- Volunteers
- Obtained clinic volunteers in peds to help watch siblings or assist with patient so parent and physician can talk
- Obtained clinic volunteers in peds to help watch siblings or assist with patient so parent and physician can talk
- Schedule holds
- One hour per day devoted to MH patients
- Arranged Standing Orders in the lab without pre-scheduled appointment
- Transition Packet
- Social worker assists with providing printed materials, making phone calls, and office visits
- Initiated use of PRR (Please Room Right Away) Card
- PRR Card also works in the ER and urgent care
- PRR Card also works in the ER and urgent care
- Improved usage of wheelchair scale
- Worked on development of pictoboard
- Developed a “Clothes Closet” for emergency clothing needs
- Parking – under clinic
- The Healthy Development Through Primary Care Project
- Started standardized screening with ASQ, with billing for testing
- DHS Work Group – Reimbursement for Care Coordination
- Working with Epic to become more user friendly
- Working on Duluth Children’s Clinic/Medical Home Website
- Care Plan 101
- Working with ER for next day follow ups
- Implemented AAP Autism Tool Kit
- Establishing a list of local dentists that will take on Medical Home patients into their practice
- Working on Respite Protocol
- Working with hospitalists on Direct Admission Protocol
- Developed Asthma Protocol
- Evaluating whether to dispense more than 30 day supply of ADHD medications
- Now billing for Newborn Weight Checks
- Spreading Medical Home Awareness
- Parent to Parent Medical Home education via parent partner phone calls
- Explore binder and care plan tube as tools for families
Grand Itasca Medical Home Team
Grand Itasca has a catchment area of 40,000 people even though the town
is just 8,000. Our medical home tries to serve all kids who meet the
definition of special needs, basically any child who requires more than
usual medical care. We've recently started using the special needs
screening tool and find that we are picking up many more children than
we had previously recognized. Our clinic will be getting an electronic
health record and we hope that if data is entered into the record with
special health needs identified, we will be able to provide more
proactive care.
Each year we have an Asthma camp to try to address the needs of kids with asthma and teach them that their asthma shouldn't limit them. For the past two years we've had a pizza party for our special needs kids. It's a fun night out for the kids and it gives parents a chance to network. An event for out kids with Down syndrome is in the works.
The medical home also helps us to focus on routine health maintenance. We've started to ask some of our kids to come in for chronic care visits to make sure care is well coordinated. Plans are reviewed and parents are involved as part of the team. We're using templates for our well child exams to be sure that care is comprehensive and uniform among providers. We are also working with the schools to improve our immunization rates.
The medical home team has been part of some building improvements. One parent partner donated money towards a wheelchair scale, so that we could weigh our special needs kids better. Our team wrote a grant which was awarded by the hospital foundation to create a procedure room to make lab draws and procedures less traumatic for our kids.
Jan Rourk Grand Itasca
Primary Care Provider Partner
