PCMH 2017
Care coordination resources, including a sample patient care plan can be found at:
https://www.aap.org/en-us/professional-resources/practice-transformation/managing-patients/Pages/Care-Coordination.aspx
National Center for Medical Home Implementation Building Your Medical Home Guide:
https://medicalhomes.aap.org/Pages/Managing-Your-Patient-Population.aspx
https://medicalhomes.aap.org/Documents/PediatricCarePlan.pdf
NICHQ Care Plan Template: https://www.nichq.org/resource/nichqs-care-plan-template
PCMH 2017
Pediatric practices are not penalized for not sharing information with parents if the adolescent requests that information not be shared, but applicants must explain the exclusion of adolescent patients in the associated documentation. The system must include only legitimate requests for information based on state and federal confidentiality requirements
Confidentiality considerations in the care of young adolescents, AAP News 2008;29;15: http://aapnews.aappublications.org/cgi/reprint/29/7/15.pdf
PCMH 2017
No, but health literacy training programs are only a suggested approach for addressing communication needs and reducing barriers for patients and their families to access and understand health and safety information.
PCMH 2017
For younger children, practices may also identify patients and provide outreach for services for developmental screenings, autism screening, oral health risk assessment, Hematocrit or Hemoglobin screening, iron supplements for children ages 6 to 12 months at risk for anemia, or tuberculin testing for children at higher risk for tuberculosis
For adolescent patients, other preventive care services could also include (but not limited to) patients in need of specific preventive care-related lab tests, alcohol and drug screening, cervical dysplasia screening for sexually active females, sexually transmitted infection prevention counseling for adolescents at higher risk, obesity screening and counseling, HIV screening for adolescents at higher risk or other required screenings (e.g., chlamydia, depression, dyslipidemia at specific ages).
AAP resources:
Recommendations for Preventive Pediatric Health Care (PDF): https://brightfutures.aap.org/materials-and-tools/PerfPrevServ/Pages/default.aspx
Interactive Periodicity Schedule (AAP Pediatric Care Online- Web resource): https://pediatriccare.solutions.aap.org/periodicity-schedule.aspx
Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition (Web site and links to associated text/materials): http://brightfutures.aap.org/index.html
PCMH 2017
Practices can use two methods to collect language need information:
1. Collect data from all patients and their families to create a report showing language needs.
2. Obtain data from an external source (e.g., data about the local community or its patient population).
Patients who do not speak English and patients from racial/ethnic minority groups may be less inclined to provide this information. Care should be taken to request the information using methods that respect multi-cultural differences.
Pediatric-specific resources:
Medical Home Data Portal state pages:
http://www.childhealthdata.org/browse/medicalhome
KIDS COUNT Data Center:
http://datacenter.kidscount.org/data/acrossstates/Rankings.aspx?ind=103
PCMH 2017
If the condition is acute care management, the plan may be simpler than for a patient with a complex, chronic condition. The plan of care would include current medications, tests, treatment, patient/family self-care and important information about the family. While not every referral would have the same level of detail, be prepared to show a referral example for a patient that does have a care plan with the expected details.
PCMH 2017
