Adolescent-centered Medical Home: Family Physicians Provide Transformational Healthcare

Ann Fam Med. 2013 May; 11(Suppl one): S90–S98.

Medical Abode Transformation in Pediatric Primary Care—What Drives Change?

Jeanne W. McAllister, BSN, MS, MHA,¹ Westward. Carl Cooley, Doctor,¹ Jeanne Van Cleave, Dr.,² Alexy Arauz Boudreau, Physician,² and Karen Kuhlthau, PhD^two

Jeanne W. McAllister

¹Center for Medical Home Comeback, Crotched Mountain Foundation, Agree, New Hampshire

West. Carl Cooley

^aneCenter for Medical Home Improvement, Crotched Mount Foundation, Agree, New Hampshire

Jeanne Van Cleave

^twoCenter for Kid & Adolescent Wellness Research and Policy, Massachusetts General Hospital, Boston, Massachusetts

Alexy Arauz Boudreau

²Center for Child & Adolescent Health Research and Policy, Massachusetts General Hospital, Boston, Massachusetts

Karen Kuhlthau

²Middle for Child & Boyish Health Research and Policy, Massachusetts General Hospital, Boston, Massachusetts

Received 2012 Jun 21; Revised 2013 Jan 25; Accepted 2013 February 8.

Abstract

PURPOSE

The aim of this report was to narrate essential factors to the medical abode transformation of high-performing pediatric primary intendance practices half dozen to 7 years after their participation in a national medical home learning collaborative.

METHODS

We evaluated the 12 primary care practice teams having the highest Medical Home Index (MHI) scores subsequently participation in a national medical home learning collaborative with current MHI scores, a clinician staff questionnaire (assessing adaptive reserve), and semistructured interviews. We reviewed factors that emerged from interviews and analyzed domains and subdomains for their agreement with MHI and adaptive reserve domains and subthemes using a procedure of triangulation.

RESULTS

At six to 7 years later on learning collaborative participation, iv essential medical home attributes emerged equally drivers of transformation: (1) a culture of quality improvement, (2) family-centered care with parents as improvement partners, (3) team-based intendance, and (4) care coordination. These high-performing practices developed comprehensive, family-centered, planned care processes including flexible admission options, population approaches, and shared care plans. 11 practices evolved to utilize care coordinators. Family unit satisfaction appeared to stem from ameliorate access, care, and safety, and having a strong relationship with their wellness intendance team. Physician and staff satisfaction was loftier even while leadership activities strained personal time.

CONCLUSIONS

Participation in a medical habitation learning collaborative stimulated, just did not complete, medical abode changes in 12 pediatric practices. Medical home transformation required continuous development, ongoing quality improvement, family partnership skills, an mental attitude of teamwork, and strong care coordination functions.

Keywords: alter, organizational, children with special wellness intendance needs, disabled children, medical home, do-based inquiry, main intendance, transformation

INTRODUCTION

The patient- and family-centered medical home grounds U.s. Maternal and Kid Health Bureau policy and represents a strategic priority of the American Academy of Pediatrics. ^i,ii The Academy states that all children deserve a medical home—a source of accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care. To date, little is known, however, about enablers of successful medical home change and whether quality comeback (QI) is an essential tool for transformation. ³ We studied 12 practices showing loftier performance afterwards their participation in a QI learning collaborative to narrate attributes of transformed pediatric medical homes.

METHODS

In 2003, the Center for Medical Home Improvement and the National Initiative for Children's Healthcare Quality conducted 2 twelvemonth-long, nationally based learning collaboratives to foster implementation of the medical home model for children and youth with special health care needs. ^iv Twoscore-five exercise teams participated. Teams consisted of a pediatric physician champion, 2 "parent partners," and, optionally, a care coordinator. They completed the validated Medical Domicile Index (MHI) ^five before and afterwards learning collaborative participation (data points one and two). Core components of the learning collaborative included the Chronic Care Model translated for pediatrics equally the Care Model for Child Health in a Medical Home, which promotes a team arroyo to population care and family-centered care coordination. ^6,7

Sample

Nosotros used a modified positive deviance approach to select 15 loftier-performing practices from 2 collaborative cohorts based on postcollaborative MHI scores at the cease of the collaboration. ^viii Of the xv invited, 2 had lost their medico champion and 1 was unable to proceeds administrative approval; thus, 12 practices agreed to participate. The geographic distribution, urban-rural location, and exercise type of the studied and nonstudied sites did not differ. Research funding allowed for 15 practices with no retrospective comparison. To further verify exercise quality, nosotros nerveless additional information in 6 practices with the highest MHI scores. We performed pediatric quality intendance audits of patient charts and administered the Modified Consumer Assessment of Healthcare Providers and Systems Health Program Survey 4.0 Version: Child Medicaid Questionnaires (CAHPS) to appraise the family unit perspective. ^9–12

Crotched Mountain Foundation's institutional review lath approved the study.

Data Collection

We used a mixed methods arroyo incorporating iii primary data sources—the MHI, a clinician staff questionnaire, and semistructured interviews—in each of the 12 practices, as described below. The study tools used are available online (http://world wide web.medicalhomeim-provement.org).

Medical Home Index

Each practice completed a current MHI cess in 2010, six to 7 years after participation in the learning collaborative (data point iii). The MHI assesses 25 indicators of medical "homeness" organized under half-dozen do domains: organizational capacity, chronic status management, care coordination, customs outreach, data management, and quality comeback. Indicators are measured across iv levels of achievement: level 1 represents basic care; level ii, responsive care; level three, proactive care; and level 4, comprehensive care. An viii-point Likert scale measures structures and processes beyond these levels; results are reported as domain hateful scores, and total MHI scores are expressed as a per centum of a maximum of 100. Higher values betoken greater levels of the attribute.

Clinician Staff Questionnaire

The clinician staff questionnaire was completed by the physician champion and the care coordinator or staff member. ¹³ We added a question to this questionnaire to measure adaptive reserve, the squad's ability to make and sustain change. Twenty-3 items address QI, teamwork, and trouble solving using a 5-point Likert scale. We converted total mean scores to a 100-point scale to allow comparison with MHI scores. Higher values indicate greater levels of the attribute.

Semistructured Interviews

Two researchers conducted semistructured interviews at each of the 12 practices between November 2010 and May 2011. Interviews were conducted individually with the medico champion, ii parent partners having children with special wellness care needs, and a care coordinator. Interviewees were original learning collaborative squad members or someone currently in their role. All medico champions were previous collaborative participants. If original parent partners were unavailable, parents currently involved with medical abode QI effort were invited, equally occurred in a single practice. Coordinators interviewed were current staff.

The focus of interviews was to place factors that facilitated adoption of the medical home model, and understand its impact on the practice, children, and families. Questions were designed to appraise factors that enabled medical home improvements; characteristics that currently made the practice a strong medical home; and impact of the medical home on parents, children, clinicians, and staff.

Data Direction

MHI and adaptive reserve scores were electronically reported to the Center for Medical Home Comeback's secure database; confidential results were password protected and accessible only to the inquiry team. Interviews were recorded, transcribed, and entered into NVivo software version 9.0 (QSR International Pty Ltd) and held securely by the Center for Boyish Enquiry and Policy at Massachusetts General Infirmary.

Assay

We used a deductive arroyo to analyze the interview data. We applied a coding scheme developed by written report authors having prior understanding of medical home innovations. ^{five,xiv–17} Coding domains included (1) helpfulness of the original medical home learning collaborative, (2) key internal and external factors affecting transformative change, (three) key medical home manifestations in practise, and (4) impact on children, families, and practices. We added subdomain factors when new concepts emerged.

We considered coding factors consistently as to whether they presented barriers to or facilitators of improvement, merely rejected that approach because factors proved to be more than nuanced. Initial coding therefore simply captured the presence of a factor; valance was addressed and integrated beyond themes and attributes. We attempted to capture the dominant views and values of interviewees while discussing alternative perspectives.

All authors participated in interviewing; ii authors coded interviews from each practice. We analyzed adaptive reserve for physician champions and coordinators as total mean scores and equally uncoupled individual scores, allowing for comparison. Interview coding intensity was examined for accent of emergent themes. We reviewed coding domains and subdomains, and analyzed them for their understanding with MHI and adaptive reserve subthemes. This strategy allowed for the triangulation of the MHI and adaptive reserve to dominant qualitative interview domains. ¹⁸

RESULTS

Practice Characteristics

Characteristics of the practices six to 7 years after their participation in the national medical home learning collaborative are shown in Table 1. The practices were diverse. I-third did not take any source of supplemental support for medical dwelling house initiatives.

Tabular array 1

Practice Characteristics

Do	Years Since MHLC	Location	Exercise Type	Ownership	Patients, Visits per Yr, No.	Registry of Number of CYSHCN	Exercise-Based Care Coordinator Role	Supplemental Medical Home Supporta
i	7	Mountain land	Academic continuity dispensary	Bookish	4,000 visits	No	Yeah	Coordination grant from medical school
2	7	Mountain state	Private, rural, small (two clinicians)	Contained, modest	528 patients, 2,000 visits	Yes	No	No extra back up
3	half dozen	Mid Atlantic	Multispecialist network, suburban, urban	Hospital owned	22,500 patients	Yes	Yeah	No extra support
4	7	Northeast	Academic medical eye	Infirmary owned	6,790 visits	Yeah	Aye	Limited Medicaid PCCM
5	7	Mountain country	Network, suburban and rural	Hospital owned	xiii,511 patients	Aye	Yes	Small AUCD/LEND contract for care coordination
6	6	Midwest	Private, suburban	Independent, large	12,000 patients, vii,000 visits	Yes	Aye	No extra support
7	7	Midwest	Private, suburban	Independent, large	xiii,000 patients	Yes	Yes	No extra support
8	6	Southward central	Community health center, Hispanic	Customs health center (FQHC)	thirteen,410 patients	Yes	Yes	Medicaid $3–$5 PMPM to "keep population well"
nine	seven	Midwest	Integrated network, urban	Hospital owned and based	4,600 visits	Aye	Aye	Medicaid payment for 300 complex patients
10	7	Mid Atlantic	Suburban network	Hospital endemic	6,000 visits	Yes	Yes	Small PMPM
11	7	Mid Atlantic	Private, suburban, multisite	Independent, large	12,000 patients	Yes	Yes	Health plan P4P
12	half dozen	Midwest	Network, suburban	Infirmary owned	27,597 patients	Yes	Yeah	PMPM for circuitous patients

Quantitative Results

Figure one shows the practices' total, transformed MHI scores at the precollaborative, postcollaborative, and current (2010) time points. Scores had improved from baseline by 21% at the end of the collaborative. Furthermore, scores improved an additional 13% from the postcollaborative time point to the current fourth dimension point. The greatest improvement was seen in the domains of intendance coordination and chronic condition management, followed past the QI domain.

MHI scores for the practices at 3 points in time and adaptive reserve (N = 12).

MHI = Medical Domicile Alphabetize; MHLC = Medical Dwelling house Learning Collaborative.

Note: Full MHI scores are expressed as a percentage of a maximum of 100; higher values bespeak greater levels of "homeness." Adaptive reserve scores are expressed on a 100-point calibration, with higher scores indicating greater reserve. The MHI and adaptive reserve scores were correlated (Pearson coefficient=0.867).

Figure 1 also shows the practices' adaptive reserve scores (transformed to a 100-point scale) in human relationship to their MHI scores. The adaptive reserve total mean score of 75.0 was correlated with the electric current MHI total scores (Pearson coefficient = 0.867). Adaptive reserve was higher for physicians than coordinators for perceived time for improvement, professional person growth, and teamwork. Intendance coordinators scored college for learning from mistakes.

Qualitative Results

Table two summarizes the interview information analyzed according to our coding scheme, counted quotes, and factor emphasis. A total of seven,302 interview quotes were counted and coded. Interrater reliability was adept with κ scores ranging from 0.81 to 0.94 (physician champions), 0.81 to 0.95 (intendance coordinators), and 0.88 to 0.96 (parent partners). The thematic findings are described below, with some examples of comments by interviewees.

Tabular array 2

Semistructured Interview Domains and Summit Subdomains

Domain and Subdomain; Items Coded, No. (%)a	Subdomain Coding Density	Subdomain Particular	Essential Medical Home Attribute(s) Supportedb
Medical Dwelling Learning Collaborative; 223 (3)
In what way was the Medical Domicile Learning Collaborative helpful?c	57	Provided data/tools/measures	QI
	47	Family participation congenital in	FCC
	47	Provided structure and standards for the transformation try	QI
Drivers/barriers for practise transformationd; ii,850 (39)
Fundamental internal/external factors that help/hurt a practice transform to a medical habitation?	516	Ability to be reimbursed	—
	352	Leadership	QI
	324	Patient collaboration/encouragement	FCC
	268	Practice environment/extended environment (eg, hospital linked to do)	—
	244	Staff capacity	TBC
	208	An electronic health record	—
	143	Gained time for innovation and reflection	QI, TBC
Medical home characteristicsdue east; 3,429 (47)
What are the important (characteristics) features/factors of the medical home model in this site?	681	Care coordination/planned coordinated care	CC
	663	Family-friendly materials and deportment; family participation	FCC
	422	Teamwork, mental attitude	TBC
	252	Intendance plan	CC, FCC
	247	Community engagement and resources	CC, FCC
	232	Focus on children with special health intendance needs as population	QI
	226	Access and communication about access	CC, FCC
Fundamental outcomes of becoming a medical homef; 800 (11)
Medical home outcomes/impact on staff and patients/families?	338	Patient satisfaction	—
	267	Quality of intendance	FCC/CC
	182	Clinician/staff satisfaction	—

Quality Improvement

Physicians benefited from peer-based learning, identifying the learning collaborative as "what got them started" using an ongoing QI process. Eleven of 12 practices developed formalized QI team processes including active parent partner participation. All expressed the need for standards and structures to guide their improvement efforts, and time for reflection and planning. They viewed their QI processes as crucial, but indicated that substantial personal time and working on multiple fronts were required to make headway.

I call back medical abode is a procedure. I don't call up it's an endpoint, information technology'due south constantly evolving; if you get one affair going, there'southward e'er something else yous tin can ameliorate upon. QI should be a way of practice life (doc champion, practice half-dozen).

Family unit-Centered Care

Family-centered care was a theme supported by all three chief data sources. The MHI specifically inquires about staff understanding and applying family-centered concepts; 75% responded that they had "full knowledge and regularly practical family-centered concepts."

Adaptive reserve does not address family unit centeredness, but we added a relevant argument to the questionnaire: "Youth/family involvement in planning and quality improvement is routinely valued and adept hither." The mean score for this statement was eighty%, reflecting strong agreement. Interview information supported how practice teams valued parent partner participation.

Parent partners told their stories, expressed goals and needs, suggested changes, and shared community resources; all benefited. Doc champions found this parental interest motivating only best-selling that the recruitment, orientation, and engagement of parent partners were hard. Virtually parent partners still used the do for care and helped with QI efforts. I instance shows how parents contributed to squad learning:

There was that independence slice for my daughter. She's going to have to do this all her life. So nosotros talked with our medical home team. Nosotros needed to piece of work on her independence, starting with checking herself in for appointments. I helped with the grooming, and the front desk was very good about letting her deed for herself at hereafter visits (parent partner, practice half-dozen).

Team-Based Intendance

Squad-based care is a concept integrated across the MHI; higher scores reverberate stronger team qualities. The adaptive reserve mean score of 75% suggests a loftier level of squad-based communication/collaboration, representing a combined ability to make, tolerate, and sustain modify. Teamwork and mental attitude were emphasized in interviews equally energizing and critical to quality. Interviewees described the spread of teamwork beyond clinicians and staff.

Information technology starts as the family walks off that elevator. Everybody—patients and staff—empathize that this is a medical dwelling house. Teamwork really drives the whole concept; everyone is involved from every level (care coordinator, do 4).

I take a partner in the complex care of my child, the team here, they have our backs (parent partner, practice nine).

Care Coordination

For the 6 MHI indicators in the care coordination domain, hateful scores nearly doubled from before the collaboration (iii.82) to after the collaboration (half-dozen.39), demonstrating an improvement. Adaptive reserve scores reflect the combined achievement of clinicians and coordinators. Almost half of coded domains and subdomains, or 3,429 of them, were related to coordination; 59% of these domains/subdomains were associated with team-based, planned, coordinated care. Care plans developed in partnership with families were attributed with outcomes including safety, reliability, and reduced wastefulness.

At the onset of the collaborative, none of the 12 practices had a coordinator position; past 2011, all merely the smallest exercise supported this position within their budget, with external grant funding, or both. Adding the part of intendance coordinator increased capacity to exist proactive, support families, and reach out to communities. Physicians said they would "not become dorsum" to their previous care model.

Coordination of care, using care plans, is amazingly effective. We have a well-child visit and create a intendance programme; and then six months later hold a chronic care visit, it's similar the problems melt away; unplanned hospitalizations tend to go abroad (medico champion, exercise 12).

We saved that family unnecessary visits and tests—that was a result of having a coordinator to help right the ship a petty bit (physician champion, practice iv).

Care coordination back up is and so helpful; it is all I would do. Our family has benefited, I tin exist a parent (parent partner, practise two).

Care Quality and Satisfaction

Parents whose children live with chronic conditions described having a "2nd home" and "trusting relationship" with their care team. Inclusion as "partners" demonstrated professional respect of the parent viewpoint and of their major role in their child's life. Equally ane noted, "This practise is my lifeline" (parent partner, practice 7).

Practices reported important care improvements tailored to complex patients, but too described how their efforts stretched to improve preventive and acute care for all children/youth.

I would have told you in the beginning that the medical home was coordination for kids with special needs; making a smooth transition from medical home to specialist; making certain they take medical information when hospitalized; receiving follow-up care. Just a medical home is ensuring children who need well-child checks, good access to care coordination, and direct access to the team, have these. My optics accept been opened (doc champion, exercise 10).

Clinicians and coordinators described an enhanced sense of professional satisfaction. The pediatric medical dwelling became a special niche and more gratifying career path for them.

I love what I do, in part because of the medical home; I have more fourth dimension with my patients; I earn less, but am happier (physician champion, practice 10).

It makes my life rich working with these kids; the medical domicile provides an innovative expanse of involvement for me, a challenge; no condition scares me anymore—this is my new frontier (doctor champion, practice 11).

Alternatively, supports for pediatric improvement were described as minimal and QI was described every bit strenuous. Physicians worried about inequitable levels of risk exposure every bit a outcome of caring for circuitous patients. They were disturbed well-nigh sustaining their mission while coping with exercise standards demanding an unsupported level of quality. ^2,19 There was concern that the pediatric medical abode was being left backside in the midst of initiatives focused on cost savings for chronically ill adults. ^20–22 Operationally, medical abode activities could be overwhelming and required the personal time of many nights and weekends.

Professional person standards call us to meet quality indicators not supported by the payment arrangement (physician champion, practise iv).

Leadership here is a volunteer activeness (physician champion, exercise 11).

Triangulated Results

Tabular array iii shows results of the triangulation of the MHI and adaptive reserve to the dominant qualitative interview domains.

Table iii

Principal Data Sources Analyzed Across Essential Medical Abode Attributes

Essential Medical Habitation Aspect	Primary Data Source
	MHIa	Clinician Staff Questionnaireb	Semistructured Interviews
Continuous QI	MHI domain of QI was most improved theme between precollaborative time point (iii.16) and electric current time point (five.79)	AR mean score was 0.75; of 23 AR items, 12 relate to QI functions	Interviews emphasized QI as ongoing and enduring (rather than rapid, time-limited transformation)
FCC	MHI question near "exercise knowledge and application" of FCC principles; 100% of cohort knowledgeable and sometimes (25%) or regularly (75%) apply FCC	Mean score for CMHI question on practice team "value of family engagement" was 0.eighty	Interviews emphasized value of family involvement in the MHLC; this emphasis continues today; practise actions and materials emphasized FCC
Squad-based care/teamwork	MHI scores converted to a 100-bespeak scale improved overall betwixt precollaborative and current time points (34%); concept of "squad" integrated across the MHI	AR mean score was 0.75; AR is a measure of the squad'southward ability to make and sustain changes	Interviews highly emphasized teamwork and team attitude
CC (team-based CC)	MHI domain of CC improved between precollaborative time point (3.82) and current time indicate (6.39)	AR mean score was 0.75; combines and averages pb PCP and CC scores (every bit key team members)	Interviews of highest emphasis included quotes referencing CC, teamwork, and attitude (of 47% characteristic quotes fifty% accost)

Word

Data from this study suggest several of import points relevant to factors that enable transformation, including 4 essential medical dwelling house attributes: (1) a civilisation of QI, (2) the delivery of family unit-centered care, (3) the value of team-based care, and (4) a focus on care coordination. ^{xiv–xvi,23–25} Care quality and satisfaction were besides axiomatic.

Rapid medical home transformation, leading to a point-in-fourth dimension metamorphosis, did non resonate with physician champions, parent partners, or care coordinators. Rather, a vigilant, ongoing process of family-centered QI resulting in continued transformation did resonate. The original learning collaborative was credited with initiating change merely not completing information technology. Ongoing QI, family unit participation, teamwork, and care coordination were articulated and supported every bit necessary pediatric medical home attributes. Delivering care within a family unit-centered medical home proved highly satisfying to physicians and coordinators. As efforts expanded, professional gratification and staff resilience appeared linked. Family satisfaction was evident in interviews and surveys, contrasting with neutral findings in other demonstration evaluations. ²⁶

Today the medical dwelling is promoted in pediatrics as a standard of quality intendance for all children. Our results reflect this shift. A sometime perspective of "our medical home children with special health intendance needs" is shifting to "our medical habitation arrangement of intendance for all children and youth."

Care coordination was described as "probing, intense, detective work" helping families navigate the health care arrangement. Lack of payment for intendance coordination was troubling and on each doctor champion's mind.

Our results are similar in some respects to those of the Medical Home National Sit-in Project ²⁷ but more than express in resources and scope. Participants in that projection described the importance of adaptive reserve, motivated team members, and positive impacts of facilitation on practise change. ^28,29 Ongoing facilitation was non available to our 12 teams. Both studies show most identical levels of adaptive reserve. ²⁸ Alignment with medical home characteristics, variation of model element implementation, and evolving shifts of personal thinking about quality are like. ^xiii Larger organization and policy supports for primary care are commonly stressed needs.

Limitations

Several factors must be considered when interpreting these results. Two of the authors (J.W.G., West.C.C.), every bit developers of the MHI and kinesthesia members for the original learning collaboratives, may have introduced bias. The appointment of neutral researchers (J.Five.C., A.A.B., and M.K.) in all aspects of study design may have mitigated this bias to some degree. The selection of high-performing practices allowed a focus on positive attributes associated with successful transformation. Information gleaned by studying less successful practices may accept augmented our factors and allowed for comparison; such a study would be an important next step.

The practices we studied had multitalented teams and potent parent partners providing lessons perhaps not generalizable to practices nationally. Interviews targeted only the physician champion and care coordinator as informants, mayhap limiting reports.

Finally, contextual factors undoubtedly influenced the study results and may touch on the ability to transport the findings to other settings. These factors are summarized in the Supplemental Appendix (available online at http://annfammed.org/content/11/Suppl_1/S90/suppl/DC1).

Implications

Our findings suggest that efforts to build and cultivate the pediatric medical dwelling will benefit all children, their families, and clinicians alike, while enhancing care quality. Despite the above limitations and a potential demand for broader report including more practices and staff, we feel ours is an important initial endeavor to identify disquisitional transformative factors within pediatric primary care. Our results suggest that successful improvement toward the pediatric medical domicile model will require (one) QI supports with capabilities to drive change, (2) skill development to engage families every bit care and improvement partners, (3) competencies to ensure constructive team-based, comprehensive care, (4) care coordination functionalities, and (5) payment aligned with the delivery of loftier-quality care.

Acknowledgments

We would like to admit the leadership, communication, guidance, and ongoing communication and coordination of the post-obit 12 pediatric medical home practices: Saint Mary's Hospital – Children'south Health Middle, Waterbury, Connecticut; Due north Arlington Pediatrics, Illinois; Henry Ford Pediatrics, Detroit, Michigan; St Cloud CentraCare (Pediatrics), St Cloud, Minnesota; Chapel Hill Pediatrics and Adolescents, North Carolina; Prime Care Pediatrics, Zanesville, Ohio; Children's Hospital of Philadelphia Intendance Network, High Point, Pennsylvania; Lancaster General Health, Roseville Pediatrics, Pennsylvania; Su Clinica Familiar, Texas; Dr Robert Terashima'south Practice, West Jordan, Utah; Pediatric Dispensary at the University of Utah; and Intermountain Health Care/Budge Dispensary/Pediatrics/Logan, Utah, as well as our written report team members: Michelle Esquivel, MPH; Charles Homer, Physician; Jennifer Lail, Physician; Marilyn Peitso, MD; Sylvia Pelletier; Renee Turchi, Physician; Vera Tait, Dr.; Robert Southward. Woodward, PhD, CMHI; and staff Lori Keehl Markowitz, BSN, and Leah Reed.

Footnotes

Conflict of involvement: authors study none.

Funding support: This work was supported by Agency for Healthcare Research and Quality (AHRQ) grant R18HS019157-01 and in office by the The states Maternal and Child Wellness Agency (USMCHB), Sectionalization for Children with Special Health Care Needs (CSHCN). The medical domicile learning collaborative described herein was funded nether a cooperative agreement with the USMCHB CSHCN. Participation of each practise team was supported past their country Championship V Program dedicated to the care of CSHCN. Boosted funding support included NIMH grant K23MH083885 and NIMH grant R25MH080916.

Disclaimer: The authors of this article are responsible for its content. Statements in this presentation should not exist construed every bit endorsements by the AHRQ or the Us Department of Wellness and Human Services.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3707252/

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