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Read this report of inspiring stories from Phase One of the Be Our Voice project.

Transitioning Into a Patient-Centered Medical Home

December 2012
By Julie Eisen 

How does a medical practice shift its culture to deliver higher quality, patient-centered care? This is the challenge that 13 pediatric practices across Massachusetts accepted over a year ago as part of the CHIPRA Massachusetts Medical Home Initiative. In this project, teams at each of the 13 practices are making changes to create an office environment that supports the values of a patient-centered medical home—primary care that is accessible, compassionate and culturally effective to all children and their families.

In the past 16 months, these pediatric practices have been working to establish or improve procedures, such as:

  • Involving parents in decision-making to create protocols that make sense for their families
  • Walking patients and families through their medical histories and developing a care plan that they can bring to other providers
  • Adapting an office’s practices to meet the needs of an immigrant population

These small changes add up to a clinical experience that is tailored to the needs of the patient. By the end of 2013 the goal is for each of the practices to have transformed into patient-centered medical homes. NICHQ is facilitating this transformation by providing a supportive framework and community for participating practices. Reflecting on the last year, several practices share the strides they have made in the important areas of family engagement and education, patient care planning and cultural competency.

Parent and Family Engagement

Understanding the family experience is critical to developing and improving the way a medical practice operates.

Harvard Vanguard Medical Associates (Chelmsford, MA)
Sally Faggella, Practice Transformation Facilitator
What we did: Held a family focus meeting
Details: We began by asking those attending to write down on a piece of paper what our practice was doing right to meet their child’s needs and what needed improvement. Several parents with autistic children attended, and one parent explained that their child needed to be roomed as soon as possible to avoid overstimulation in the waiting room.  Another parent spoke up and said the opposite, “please do not room my child until the last minute because he cannot tolerate being in a closed exam room.” 
Takeaway: Families can provide nuanced information about their children that might not otherwise be captured. The discussion illuminated that each special needs child requires a written plan for their visit that encompasses more than their medical needs.

Holyoke Pediatric Associates (Holyoke, MA)
Michele Giarusso, Practice Transformation Facilitator
What we did: Formed a family advisory group
Details: A group of 11 family members has provided input on our pre-visit questionnaires, transition-to-adulthood letters and policy, customer service and the patient experience, topics for the informational bulletin boards in our waiting room, and requested skills-building workshops for parents.  Based on this guidance, we have selected bulletin board topics, are holding an Internet health literacy workshop for parents in January 2013, made suggested changes to our transition documents and are similarly amending our pre-visit questionnaires.
Takeaway: Having a diverse group of provide input on office protocols offers valuable ways to create an environment that suits patients’ needs.


Parent and Family Education

In addition to collecting families’ feedback on the practice, part of patient-centered care is ensuring that families are empowered with the knowledge and tools needed to make medical decisions for their children.

  A parent partner from Patriot Pediatrics in Bedford, MA, shares her experiences with a group of other parent partners.

South County Pediatrics (Webster, MA)
Suzanne Grochowski, Practice Transformation Facilitator
What we did: Created a digital bulletin board in the patient waiting room
Details: The digital bulletin board runs a slideshow with information on making well visits, scheduling flu vaccines, tips on treating colds and fevers and other reminders. The information we post on the board is meant to empower families by increasing their knowledge and reinforcing good parenting skills. The front desk staff have noticed an uptick in the number of patients, while waiting for sick visits, that are coming up to book physicals for siblings and for flu vaccines.
Takeaway: Taking advantage of wait times with a visually appealing way of delivering patient reminders can prompt families to make important appointments.

Cambridge Pediatrics (Cambridge, MA)
Ziva Mann, Family Partner
What we did: Organized educational family workshops
Details: The team decided to set up three workshops, in hopes that we'd be able to build community over the course of the workshops. We found a parent coach, Danya Handelsman, to run the series, and asked her to work with us to choose topics that would appeal to a broad spectrum of families, whose children had a range of ages. The topics are taming tantrums, building connections/relationship with your child, and what to do when your kids push your buttons. We also arranged for childcare and a light dinner to be served at each workshop. And, for the third workshop, we've got a professional storyteller, Andrea Kamens, coming to entertain the children. 
Takeaway: Think outside of the box when organizing educational workshops for families and make attendance easy by providing childcare and dinner, when possible.

Care Planning

One goal of the patient-centered medical home is to offer resources to better coordinate care between the primary care provider and other parts of the healthcare system and community.

Pediatric Associates of Greater Salem (Salem, MA)
Maria Mignone, Practice Transformation Facilitator
What we did: Began creating care plans for patients
: The care plans put all of a child’s information in one place. They are very specific to the patient’s needs, and it puts the patient at the top of the triangle. For example, the care plan might list if a kid needs a water bottle at their desk in school because they have a mitochondrial disorder. Or if the child is bedridden, here is a place for the home nurse to have everything listed. It’s an organizational tool.
Takeaway: Families appreciate the process of developing a care plan that easily captures all of their child’s medical information in one place.

Harvard Street Neighborhood Health Center (Dorchester, MA)
Theresa Clark, Team Member
What we did: Began creating care plans for patients
Details: We had not used care plans before joining the project. Most families who are in need of additional medical help are happy we started this service.
Takeaway: Families feel engaged and are appreciative of the care planning process.

Cultural Competency

To deliver patient-centered care, a patient’s background and culture need to be taken into account.

  A parent partner (right) from Caring Health Center in Springfield, MA, speaks about the progress her team has made.

Caring Health Center (Springfield, MA)
Jacqueline Johnson, Practice Transformation Facilitator
What we did: Began developing cultural competency trainings
Details: We are currently developing a series of culturally competency trainings/teach-ins with the help and facilitation of two trained professionals from the University of Massachusetts. We are in the process of sending out internal surveys to help us decipher where staff’s awareness is currently, to help us create objectives and a plan for moving forward. 
Takeaway: When planning to train staff, first taking an inventory of what they currently do and do not know will help create the most effective training.

Martha Eliot (Jamaica Plain, MA)
Erin Kelly, Practice Transformation Facilitator
What we did: Created a new immigrant orientation program
Details: A team at our clinic developed a new immigrant program meant to orient recent immigrants to the health care system in the area. This program includes tours of the health center and its offices as well as of the local pharmacies and other community resources.
Takeaway: Education spans beyond the clinic walls. Adapting new immigrants to the healthcare system makes for a smoother transition.


As these small changes accumulate, a medical home starts to take shape.


 “When project teams continue to test methods to improve population health management, support family involvement in practice improvement, and develop sustainable community partnerships, these actions start to pave the way for best practices in pediatric care across childhood and adolescence,” says Dr. Shikha Anand, project director of the CHIPRA Massachusetts Medical Home Learning Collaborative and NICHQ’s director of strategic alliances.


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