Using Medical Home to build services

Introduction: Medical Home implementation provides care coordination to children and youth with special healthcare needs and other children. Physicians are aware of a growing number of children identified with obesity and behavior health issues at risk to develop complications and chronic special health care needs if suitable interventions are not provided. A federally qualified health center in Stamford CT, in cooperation with the community hospital, developed services and protocols for children as an approach to avoid negative outcomes such as diabetes or school failures. Method: Protocols were developed to ensure physician champions and staff screened children with behavior problems and overweight issues. A process to ensure delivery of mental health services was developed, linking children to The Child Guidance Center for treatment. Medical home grant funding was utilized to leverage existing care coordination resources, establishing monthly workshops providing nutrition and parenting education. Recognizing the effectiveness these services, in 2006 the hospital foundation provided a nutritionist and established a twelve-week program combining nutrition education and physical activity for families of overweight children. Results: 26 families with obese children participated in the twelve-week program. 90% of the participating children improved their BMI. The Child Guidance Center provided mental health services for 32 children annually. Building on this success, programs in four after school programs were established, serving about 250 children annually. Conclusion: Medical Home can be used as an impetus to build preventative services, reducing the risk for children to develop chronic special health care needs.