Success Stories 

The Pennsylvania Medical Home Initiative (EPIC-IC)

By Renee Turchi, MD, MPH; Deborah Walker, M.Ed.; Molly Gatto, MHA

Educating Practices in Community Integrated Care (EPIC-IC) has provided training to over 100 practices in all six regions of Pennsylvania since its inception in 2001. EPIC-IC is a collaborative effort of the Pennsylvania Department of Health (PA DOH), family organizations, and the Pennsylvania Chapter of the American Academy of Pediatrics. The Maternal and Child Health Bureau founded the initiative in 2001 and continued to support medical home through 2009. Title V funding through the PA DOH has supported the initiative from 2002 to the present.  

Some highlights of the PA Medical Home Initiative:

• EPIC-IC has successfully integrated the medical home model into diverse types of practices including pediatric/family practices, specialty practices, private practices, health system and hospital-owned practices, school-based clinics, Federally Qualified Health Centers and Rural Health Centers.
  
  
• EPIC-IC practices have cultivated a network of parent partners that also work with the EPIC-IC program statewide (n=68). A social networking site further supports parent-to-parent learning, sharing and support.
  
  
• Collaboration with Title V and the Department of Public Welfare has resulted in policy changes such as reimbursement for care plans, increased reimbursement for higher complexity visits, and reimbursement of transition-related collaboration with adult health care providers.
  
  
• During the course of the initiative, EPIC-IC has sought to assess the value of the Medical Home through the collection of outcome-based evidence. EPIC-IC practices (n=20) participated in a time tracking study in which over 80,000 encounters involving care coordination activities were analyzed. Results demonstrate a statistically significant number of emergency department visits, unplanned hospitalizations, missed parental work days, and missed school days were prevented due to care coordination activities.
  
  
• EPIC IC practices are currently participating in a survey project in which families of CYSHCN are asked about health care utilization, satisfaction, unmet needs, care coordination, sources of care, family centered care and cultural competency. Results from the survey will be linked to other data providing a detailed view of the impact that care in a medical home has on the lives of patients from the perspectives of families, providers and payors.
  
  

To learn more about EPIC IC, visit their website and watch a video, in which participating health care providers and families describe their experiences with the PA Medical Home Initiative. Join “Especially for Parents,” the web community for parents of CYSHCN. If you have questions, please contact Program Director Dr. Renee Turchi.    

Baby Steps to Health Program 

By Cynthia DeLago, MD, MPH
Director, Pediatric and Adolescent Ambulatory Center
Albert Einstein Medical Center
Philadelphia, PA 

The Baby Steps to Health Program is one of 10 Healthy Tomorrows* grants that received funding in 2009. The premise of the Baby Steps to Health Program is to help medically and socially at-risk infants and their families transition health care from the Neonatal Intensive Care Unit (NICU) to the Pediatric Center at the Albert Einstein Medical Center. To do this, a team of physicians, nurses and social workers devised ways to promote easy transitioning, starting with identifying eligible babies in the NICU, scheduling their first appointments in the Pediatric Center, and developing care plans, so the parents know all the upcoming doctor appointments, what to expect, and whom to contact for supplies, equipment and help. The program hired a patient liaison — Mrs. Cassandra Martinez — to be a primary support for the baby’s caregiver starting in the NICU and continuing until the caregiver no longer needs her support. Most importantly, she is someone the caregiver can call for questions and help. Her oversight provides a safety-net for these babies. 

Since September 2009, the program has helped 15 babies transition to the pediatric center. The first baby enrolled — Maliq Dargan — was born three months premature and weighed only 590 grams. He was discharged from the NICU when he was three months old. Maliq had a difficult medical course after discharge from the NICU. Mrs. Martinez’s support helped Ms. Taggart keep doctor’s appointments and stay on task with his care. Maliq is now nine months old and has transitioned to the Pediatric Center’s Medical Home. Ms. Taggart has become very self-sufficient and is a wonderful advocate for her son; nevertheless, when it was time to transition Maliq she said, “Maliq, grow young so you don’t have to leave Ms. Cassandra.” (see picture of Maliq, Christina and Cassandra).  

The program will continue for at least four more years and we hope to help many more babies like Maliq. 

* The Healthy Tomorrows Partnership for Children Program is a collaborative grant program funded and administered by the HRSA Maternal and Child Health Bureau in partnership with the American Academy of Pediatrics. The program supports community-based health projects that improve the health status of mothers, infants, children, and adolescents by increasing their access to health services.