Education and Resources - Tools for Success with Health Care Home Standards

Access and communication
Participant registry and tracking participant care activity
Care coordination
Care plan
Performance reporting and quality improvement

Standard: Access and communication

Summary: HCH services are offered to patients who have or are at risk of developing complex or chronic conditions, can benefit from the services of a HCH and are interested in participation; Participants have continuous access to designated clinic staff, an on-call provider or phone triage system with continuous access to key medical record information; Appointments scheduled based on acuity of need, protocol for scheduling within one business day to avoid unnecessary emergency room and hospital admissions; Information collected on patients’ cultural background, race, and primary language; plan for this info to be used to improve care; Document patients’ preferred means of communication

Access to Care and Information
TransforMED Online Resources (includes same-day appointments, group visits, e-visits and online patient services, culturally sensitive care, after-hours coverage)

Children with Special Health Care Needs (CSHCN) Screener
From the Child and Adolescent Health Measurement Initiative

Approaches to Identifying Children and Adults with Special Health Care Needs
A Resource Manual for State Medicaid Agencies and Managed Care Organizations

Evaluation of the Medicaid Value Program: Health Supports for Consumers with Chronic Conditions
Center for Health Care Strategies, Inc., August 2007

Culture Care Connection
Health care providers and organizations can now find resources to help them provide more culturally competent care here. Developed by Stratis Health and funded by UCare, it is the first Minnesota-focused online resource devoted to the subject. Among the site's tools is a free assessment for health care organizations to determine how well they meet the federal Office of Minority Health’s national Culturally and Linguistically Appropriate Services standards. It also has information on enhancing culturally sensitive services and understanding specific patient populations.

Health Literacy Universal Precautions Toolkit
The Agency for Healthcare Research and Quality commissioned the University of North Carolina at Chapel Hill to develop and test this. The toolkit offers primary care practices a way to assess their services for health literacy considerations, raise awareness of the entire staff, and work on specific areas.

Back to top

Standard: Participant registry and tracking participant care activity

Summary: HCH uses a searchable, electronic registry to record information and track patient care; Registry used to conduct systematic reviews of HCH population, manage health services, provide appropriate follow-up, and identify gaps in care

Presentation materials: How national goals, measures, incentives and meaningful use help us achieve HCH goals
Paul Kleeberg, M.D., from Stratis Health, gave a webinar in January 2011 that covered how health care providers can use health information technology (HIT)—including electronic health record (EHR) systems, patient care registries, and personal health records (PHR)—to support patient care as a health care home (HCH). The webinar also discussed the importance of ensuring that any HIT tool providers choose allows them to meet federal meaningful use criteria and any other clinical or process needs they may have.

Free or Low Cost Patient Care Registries to Support Health Care Homes (PDF: 46KB/2 pages)

Free or Low Cost Personal Health Records (PDF: 51KB/2 pages)

Webinar (archived): Free and Low-cost Registry Options
Available at Minnesota Chapter American Academy of Pediatrics
April 22, 2010 - Presenters from Stratis Health review results of their search for free and low cost health care home registry tools and resources for Minnesota clinics.

ICIC's a Registry Evaluation Form (PDF: 80KB/8 pages)
This will help to guide and structure your practice's evaluation of the available software, prior to making a purchase or implementation decision.

A Resource Guide for Using Health IT to Support the Patient Centered Medical Home (PDF)
Patient-Centered Primary Care Collaborative provides comprehensive explanation regarding the role of the EMR in the medical home.

Doctors vs. Doctors with IT Support — Who's Better? New Study Shows the Value of Health IT
The Commonwealth Fund, June 18, 2009. Brief article on the benefits of IT supported medical care.

The Rural Health IT Adoption Toolbox
The Office of Rural Health and Policy (ORHP) developed a new resource to support rural health providers seeking to adopt Health IT solutions to improve patient care. The toolbox is comprised of eight modules delivered in a Q and A format to support all stages of HIT adoption. The toolbox includes information gathered through public initiatives and materials developed by the Health Resources and Services Administration (HRSA).

Back to top

Standard: Care coordination

Summary: HCH promotes patient and family-centered care: participant is a member of HCH team; sets goals and identifies resources; Each patient has a designated personal clinician and care coordinator, co-located; HCH documents referral information, tests, admissions, discharge planning, medication information, etc. in patient’s chart or care plan

Sample Care Planning and Coordination Policy (DOC: 53KB/4 pages)
MDH staff put together an example policy for care planning. There are several examples within this example policy for clinics to chose from. The key is to operationalize the elements of this example in your policy.

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

Center for Medical Home Improvement Pre-Visit Contact Planning (DOC: 61KB/1 page)

Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework
The Commonwealth Fund, May 2009. This article also provides a link to the full PDF report of 34 pages which is worth reading for more details of care coordination.

Designing Evaluation Studies of Care Coordination Outcomes for Children and Youth with Special Health Care Needs (PDF)
Catalyst Center, June 2008

Back to top

Standard: Care plan

Summary: HCH has policies/procedures to assess which patients will benefit from a care plan; Care plan development must actively engage patients and the rest of the care team, include an assessment of health risks and chronic conditions, involve periodic review and updating in partnership with patients, and incorporate evidence-based guidelines where available; Care plan includes unique patient goals and action plans that are updated regularly

Sample Care Plans:

Screener Tools:

CentraCare CSHCN screener (DOC: 100KB/1 page)

Partnering in Self-Management Support: A Toolkit for Clinicians (PDF)
Institute for Healthcare Improvement

Comprehensive Care Planning (PDF)
From the Medical Home Learning Collaborative, Center for Medical Home Improvement

Improving Chronic Illness Care (ICIC)
ICIC has the goal of helping people with chronic illness through a coordinated program of quality improvement (QI), research and dissemination. This link is to the site map with an extensive amount of information on the chronic care model, self surveys, training and materials. The tool kit contains over 600 pages, with specific practice changes involved in chronic care model implementation presented in a step-by-step fashion, potential barriers to implementation (financial), care plans and more.

Back to top

Standard: Performance reporting and quality improvement

Summary: HCH establishes a quality improvement team that includes clinicians, care coordinators, participants and administrators if applicable; HCH measures, analyzes, and tracks changes for at least one quality indicator; HCH participates in a learning collaborative and shares information learned with other staff and patients; Benchmarks for quality established by MDH and used for continued certification; HCH measured on its entire primary care patient population

Plan-Do-Study-Act (PDSA) Worksheet
Project Planning Form
Tools from the Institute for Healthcare Improvement

Medical Home Indices for Adult, Children and Families, full and short versions, FAQs from the Center for Medical Home Improvement

Developing a Community-Based Patient Safety Advisory Council - Toolkit and Resource Descriptions
The "Guide for Developing a Community-Based Patient Safety Advisory Council" provides information and guidance to empower individuals and organizations to develop a community-based advisory council. These councils involve patients, consumers, and a variety of practitioners and professionals from health care and community organizations to drive change for patient safety through education, collaboration and consumer engagement.

Consumer Assessment of Healthcare Providers and Systems (CAHPS)
This Agency for Healthcare Research and Quality program is a public-private initiative to develop standardized surveys of patients' experiences with ambulatory and facility-level care.

CAHPS Clinician & Group Surveys
For adult primary care, adult specialty care and child primary care

Back to top

Updated Monday, 10-Feb-2014 10:00:08 CST