Medical Home: Activities

After a year of exploration and planning, the Medical Home Work Group coalesced this year from an "ad hoc" strategic planning committee to a full work group with Dr. Greg Prazar as Chair. With an endorsement from the NEGC Advisory Committee, the group set a new goal of replicating some aspect of the Genetics in Primary Care Institute (GPCI) model to integrate genetics into primary care practices in New England. 

The group identified collaborative partners within pediatric improvement programs in Maine, New Hampshire, and Vermont. Our intention is to work with the remaining states in New England at a future time. 

After a brief survey of pediatricians in NH, ME and VT, the group learned that primary care practices were most interested in care coordination, though we plan to demonstrate the importance of family history in whatever activities we do.

The group launched an educational webinar series in May 2015:

"It's All About Teamwork: Incorporating Genetics and Family History into the work of the Patient Centered Medical Home (PCMH)”

“Why Medical Home and Care Coordination are Important for Children”
Jill Rinehart, MD, Pediatrician from VT; Jeanne McAllister, BSN, MS, MHA, Medical Home Expert.
 Click here for presentation slides and recording (May 2015). 

“How to Achieve a Shared Plan of Care for Kids with Primary Care Providers, Families, and Specialists”
Dr. Jill Rinehart and Jeanne McAllister. 
Click here for presentation slides and recording (June 2015). 

“Obtaining and Documenting a Pediatric Family History – Understanding Why it is Important, Identifying Red Flags, and Capturing the Information in the Electronic Medical Record”
Craig Donnelly, MD, Pediatric Psychiatrist from NH; Leah Burke, MD, Geneticist from VT
Click here for presentation slides and recording (July 2015).

“Sustaining the Momentum / Incorporating Genetics in the Management of Children in the Primary Care Office”
Wendy Smith, MD and Rosemarie Smith, MD, Geneticists from ME
Click here for presentation slides and recording (September 2015). 

"Balancing Strengths & Needs: Family Centered Conversations"
Jill Rinehart, MD; Barbara Frankowski, MD; Tara Townsend, Family/Advocate
Click here for presentation slides and recording (May 2016).

"Family Voices: Helping Families & Professionals Maneuver the Maze of Complex Conditions"
Tara Townsend, RI Parent Information Network; Jill Rinehart, MD; Bonnie Thompson, Family/Advocate
Click here for presentation slides and recording (March 2017).

Webinars are also archived on the "Maine Quality Counts" website.


In past years the Medical Home Work Group built on a body of work developed through National Health Care Transition Center (Got Transition?) by W. Carl Cooley, MD, Work Group Chair at that time. This body of work, funded by HRSA, built a step-by-step methodology to coordinate the transition from pediatric care to adult care within a Medical Home.

The methodology was part of a clinical report published in the American Academy of Pediatrics in 2012: “Health Care Transition Planning Algorithm for All Youth & Young Adults Within a Medical Home Interaction”. The work group tested the application of this methodology in relation to specific conditions. The intent was to ensure the utility of the methodology for use in the Medical Home and to improve patient involvement in the transition process. Another feature in the clinical report, Six Core Elements of Health Care Transition, also informed the work of the group.

Prior to that, two surveys were conducted. The first survey in 2010-2011 assessed primary care physicians'’ comfort, clarity of role, and quality of communication in the co-management with specialists of children and youth with rare and/or complex chronic conditions. Findings indicated that:

  • pediatricians are more comfortable than family physicians with rare and complex cases
  • care decisions are made by specialist in consultation with PCP
  • a tool for co-management was needed. 

In 2011-2012, a second survey was conducted to complement the first survey. This survey was directed to metabolic and genetic specialists in the New England region. The results of this survey indicated that:

  • communication processes need improvement; rarely is there two-way communication: and specialists often do not hear back from PCPs that they received their reports
  • all of those surveyed strongly agree with co-management with PCPs but there isn’t enough time to do this effectively
  • specialists agreed that the best existing methods for receiving referrals was by phone or fax, best way to hear from PCPs was by phone (though time consuming and disruptive), and best way for them to communicate results of a consultation was by letter
  • they agreed that these methods were not necessarily the best possible methods, and that better two-way or three-way(including parents) communication tools were needed.

Additional accomplishments include the Pediatric Referral/Consultation Family Care Plan, a care coordination plan developed for use by parents, primary physicians and specialists. Although it is not currently in use in New England, an article was published in Academic Pediatrics in 2013: Parent Partnerships in Communication and Decisions Making About Subspecialty Referrals for Children With Special Needs. Authors include members of the NEGC work group at the time the care plan was developed: Dr. Chris Stille, Beth Dworetzky, and Dr. Carl Cooley.