Skip to main content

Health Information Center

Medical Home: A Family-centered System of Care

A medical home is not a building, but a better, family-centered way to provide care for children with special health care needs* and disabilities. In the medical home philosophy of care, information and concerns are shared by everyone caring for the child. Needs are addressed in a coordinated way, with a primary care doctor and their clinical staff serving as a coordinator of the child’s health care services. A written care plan is shared with the family and all of the child’s health care providers, and the medical home is a central place for the child’s complete records.

Sometimes also known as “health care homes,” the medical home philosophy of care for children and youth with special health care needs is specific and includes:

  • Partnership: A medical home provides patient- and family-centered care through an ongoing, collaborative partnership with families, recognizing that they are the constant in a child’s life.
  • Community-based approach: The medical home is an integral part of a community-based system of coordinated or networked services that support the health and well-being of children and their families. A physician in a medical home provides ongoing primary care and facilitates access to and coordination with a broad range of specialty and related community services such as schools.
  • Transitions: A medical home provides health care services that include careful transition to the adult system for youth, so that services and care continue uninterrupted as the youth moves from adolescence to adulthood.

A medical home physician ensures care that is:

  • Accessible – available 24 hours a day, 7 days a week in the child’s community
  • Family-Centered – recognizes the family as principal caregivers and the center of strength and support for children
  • Continuous – available from infancy through adolescence, with the same primary pediatric health care professionals
  • Comprehensive – includes sick and well care as well as education and community referral needs
  • Coordinated – includes links to support, educational, and community-based services
  • Compassionate – expresses and demonstrates concern for well-being of child and family
  • Culturally effective – recognizes, values, and respects each family’s cultural background

Why is a medical home important?

Most importantly, a medical home can improve the child’s health. Families of a child or youth with disabilities or chronic health conditions often have difficulty working and communicating with many doctors, nurses, and other health, education, insurance, and social service professionals. These families benefit from a family-centered, teamwork approach to providing care through:

  • More organized, cost-effective care
  • More efficient communication – families don’t have to repeat information to multiple caregivers
  • Support from a team of caregivers
  • Exams scheduled in a coordinated, efficient way without duplicated services

What are the roles and duties for the primary care physician and other health care providers within a medical home?

  • Know the child’s health history
  • Listen to the parents’ and child’s concerns and needs
  • Work in partnership with families to ensure that the medical and non-medical needs of the child and family are met
  • Create a trusting, collaborative relationship with the family
  • Treat the child with compassion and understanding
  • Develop a care plan with the family for their child when needed
  • Share impartial and complete information on an ongoing basis

How do I implement the medical home philosophy?

  • Discuss ways to improve care for children and youth with special health care needs and disabilities, and how to begin setting up a medical home with your colleagues and patients
  • Read the National Center for Medical Home Implementation’s webpage, Building Your Medical Home
  • Read the Tips to Understand and Implement the Medical Home Model
  • Learn more by contacting PACER’s Family-to-Family Health Information Center at 952-838-9000.

*Who are children with special health needs?

Minnesota children with special health needs (MCSHN), as defined by the Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, “are those who have or are at increased risk for a chronic physical, development, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.”
This includes children who:

  • Have a disability or chronic illness
  • Experience physical and emotional consequences from biological or environmental risks, including prematurity and extreme poverty
  • Have experienced abuse or neglect
  • Need special education or other support services
Show More

Creating a Medical Home

National Center for Medical Home Implementation | American Academy of Pediatrics
Resource for health professionals, families, and anyone interested in creating a medical home for all children and youth.

  • Building your Medical Home toolkit
    Supports the development and/or improvement of a pediatric medical home. The toolkit also gives information to apply for and potentially meet the National Committee for Quality Assurance (NCQA) Patient Centered Medical Home (PCMH) recognition program requirements.

Guidance for and current performance of established Medical Homes

National Survey of Children's Health Data Resource Center
Data on how children and youth in each state experience receiving care within a medical home

Why is Medical Home Important?
Presents various tools available and in use to identify, recognize, and evaluate a practice as a pediatric medical home.

In Minnesota: