3)  Knowledgeable/concept sometimes applied in practice 4)  Knowledgeable/concepts regularly applied in practice The Medical Home Index: Revised Short Form: Pediatric Measuring the Organization and Delivery of Pediatric Primary Care for All Children, and Families INSTRUCTIONS: This instrument is organized under six domains: 1) Organizational Capacity, 2) Chronic Condition Management, 3) Care Coordination, 4) Community Outreach, 5) Data Management, 6) Quality Improvement Each domain has anywhere from 1-4 themes; these themes are represented with progressively comprehensive care processes and are expressed as a continuum from Level 1 through Level 4. For each theme please do the following: First: Read each theme across its progressive continuum from Levels 1 to Level 4. Second: Select the (1, 2, 3 or 4) which best describes how your practice currently provides care for patients with chronic health conditions. Third: When you have selected your Level, please indicate whether practice performance within that level is: "PARTIAL" (some activity within that or "COMPLETE" (all activity within that level). For the example below, "Domain 1: Organizational Capacity, Theme 1. 1 "The Mission..." the score for the practice is: "Level 3", "PARTIAL". Italicized terms are included in the glossary beginning on page 11 of this document. Domain 1: Organizational Capacity: THEME: Level 1 Level 2 3 Level 4 #1.1 The Mission of the Practice Primary care providers (PCPs) at the practice have individual ways of delivering care to children with special health care needs (CSHCN); their own education, experience and interests drive care quality. Approaches to the care of at the practice are child rather than office needs drive the implementation of care (e.g. the process of carrying out care). The practice uses a family-centered approach to care, they assess and the needs of their families in accordance with its mission; feedback is solicited from families and influences office policy (e.g. the way things are done). In addition to Level 3, a parent/ practice "advisory group" promotes family-centered strategies, practices and policies (e.g. enhanced communication methods or systematic inquiry of family concerns/priorities); a written, visible mission statement reflects practice
Domain 4: Community Outreach: For CSHCN and Their Families THEME: Level 1 Level 2 Level 3 Level 4 #4.1 Community Assessment of for CSHCN PCP awareness of the population of children with special health care needs CSHCN in their community is directly related to the number of children for whom the provider cares. The practice learns about issues and needs related to CSHCNs from key community informants; providers blend this input with their own personal observations to make an informal and personal assessment of the needs of CSHCN in their community. In addition to Level 2, providers raise their own questions regarding the population of CSHCN in their practice community; they seek pertinent data and information from families and local/state sources and use data to inform practice care activities. In addition to Level 3, at least one clinical practice provider participates in a community-based public health need assessment about CSHCN, integrates results into practice policies, and shares conclusions about population needs with community & state agencies. PARTIAL COMPLETE PARTIAL COMPLETE PARTIAL COMPLETE PARTIAL COMPLETE Domain 5: Data Management: For CSHCN and Their Families Level 1 Level 2 Level 3 Level 4 #5.1 Electronic Data Support PCPs retrieve information/data by individual chart review; electronic data are available and retrievable from payer sources only. Electronic recording of data is limited to billing & scheduling; data are retrieved according to diagnostic code in relation to billing and scheduling; these data are used to identify specific patient groupings. An electronic data system includes identifiers and utilization data about children with special health care needs CSHCN; these data are used for monitoring, tracking, and for indicating levels of care complexity. In addition to 3, an electronic data system is used to support the documentation of need, monitoring of clinical care, care plan and related coordination and the determination of outcomes (e.g. clinical, functional, satisfaction and cost outcomes). PARTIAL COMPLETE PARTIAL COMPLETE PARTIAL COMPLETE PARTIAL COMPLETE Instructions: A) Please select and circle one level from Levels 1, 2, 3, or 4 for each theme above (circle one). B) Then indicate whether you your practice at a PARTIAL or COMPLETE ranking within that level (circle one). Note: Any italicized words are defined in the glossary on page 11.