Helping Pediatric Practices Become Medical Homes


Providing comprehensive, quality care to all children is a difficult task. Through funding made available through the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), the Centers for Medicare and Medicaid Services (CMS) sought to meet this challenge by encouraging widespread adoption of the pediatric medical home, which is a model of patient and family-centered, community-based care that provides continuity of care from childhood through adolescence and facilitates a smooth transition to adult services.


We led a 29-month learning collaborative to implement a medical home model of care in 13 practices from across Massachusetts, with the expectation that best practices would spread to other practices throughout the state and the nation. Each site has established its own Practice Transformation Facilitator (PTF) to lead the adoption of medical home characteristics with the help of a Massachusetts Department of Public Health Care Coordinator. Teams convened six times over the course of the transformation process, providing opportunities for participants to share best practices and learn from experts and peers.

Our work on the pediatric medical home began in 2003. This was one of several national and regional collaborative efforts we have led to refine and accelerate widespread adoption of the medical home model.


The 13 participating practices achieved impressive transformations around elements in the medical home model. On average, the practices:

  • Increased implementation of Wellness Assessments from 62 percent to 80 percent for ages 2-4; 63 percent to 94 percent for ages 5-12; and 80 percent to 94 percent for ages 13-18.
    • This means approximately 20,000 more children receive wellness assessments each year in these practices as a result of their transformation into a medical home.
  • Increased the percent of children and adolescents who screen positive for autism spectrum disorder, developmental delays, or behavioral health concerns who are referred to and receive follow up with early intervention from 33 percent to 79 percent.
  • Increased optimal asthma care from 63 percent to 80 percent and optimal ADHD care from 36 percent to 91 percent.
  • Increased the percent of high risk children 2-4 who are up-to-date with fluoride varnish from 4 percent to 83 percent.
  • Increased Medical Home Index Scores from 53 percent to 70 percent.



Complete Wellness Assessments for Three Age Groups - aggregated total of all CHIPRA Massachusetts Medical Home Initiative teams

By the Numbers

The 13 pediatric practices participating in NICHQ's medical home project significantly increased implementation of Wellness Assessments across all three age groups.