About Medical Home

What is a Medical Home?

A Medical Home is not a house, office, or hospital, but rather an approach to providing comprehensive primary care. In a medical home, a primary care clinician and her/his team work in partnership with the family/patient to assure that the medical and non-medical needs of the child/youth are met. Through this partnership, the clinicial team can help the family/patient access and coordinate specialty care, educational services, out-of-home care, family support, and other public and private community services that are important to the overall health and well-being of the child and family.
About Medical Home
The American Academy of Pediatrics (AAP) describes the ideal Medical Home as one that provides "accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective care." Though many implementations of the Medical Home model focus on children and youth with special health care needs (CYSHCN), "every child deserves a Medical Home." AAP Policy Statements ([American: 2004], [Rushton: 2005], [Cooley: 2004], [Council: 2005]) have codified the role of pediatricians and other primary care clinicians in providing comprehensive care for children with chronic and complex conditions and defined the Medical Home concept.
In 2007, the AAP, American Academy of Family Physicians, American College of Physicians, and American Osteopathic Association developed the Joint Principles of the Patient-Centered Medical Home (PDF Document 37 KB). Key components that have particular applicability to pediatric settings include (from
  • Family-centered partnership: Trusting, collaborative, working partnership with families, respecting their diversity and recognizing that they are the constant in a child's life
  • Community-based system: Family-centered, coordinated collaborations designed to promote the healthy development and well being of children and their families
  • Transitions: Provision of high-quality, developmentally appropriate, health care services that continue uninterrupted as the individual moves along and within systems of services and from adolescence to adulthood
  • Value: A high-performance health care system requires appropriate financing to support and sustain medical homes that promote system-wide quality care with optimal health outcomes, family satisfaction, and cost efficiency
The importance of care coordination as a key service provided by the medical home was highlighted in a 2007 by McAllister, et al. [McAllister: 2007] Evidence of the value of care coordination continues to build and guides to its implementation are available (Care Coordination Curriculum (Boston Children's)). See Care Coordination - OLD, the Portal's overview of the topic.
Information about integrating the Medical Home concept into your practice is available through Building your Medical Home: An Introduction to Pediatric Primary Care Transformation (AAP) and the Center for Medical Home Improvement, as well as at Building a Medical Home and elsewhere throughout this Medical Home Portal.

Who are Children and Youth with Special Health Care Needs?

Children and Youth with Special Health Care Needs (CYSHCN) are "those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally." [McPherson: 1998] Studies have found the prevalence of children in the United States meeting these criteria to be 12.8% [van: 2004] to 15.6% [Newacheck: 2005]. The National Survey of Children with Special Health Care Needs 2009/2010 found 15.1% of the nation's children met this definition of children with special health care needs. For information about the study and data from each state, see

For More Detailed Information:

Information about the Medical Home concept, implementation, and related topics, is available at the National Center for Medical Home Implementation, sponsored by the American Academy of Pediatrics. The site offers access to comprehensive information about national and local resources related to Medical Home and CSHCN.
The mission of the Center for Medical Home Improvement is to establish and support networks of parent/professional teams to improve the quality of primary care medical homes for children and youth with special health care needs and their families. Useful tools, assessments, and resources are available on their web site.
In 2014, the AAP updated the Building your Medical Home: An Introduction to Pediatric Primary Care Transformation (AAP) to support development and/or improvement of pediatric Medical Homes. It also prepares practices to apply for and potentially meet the National Committee for Quality Assurance (NCQA) Physician Practice Connections® Patient Centered Medical Home (PPC-PCMHTM) Recognition program requirements (see the link below).


Information & Support

For Professionals

National Center for Medical Home Implementation
The National Center for Medical Home Implementation, a cooperative agreement between the Maternal and Child Health Bureau (MCHB) and the American Academy of Pediatrics (AAP), works to ensure that all children and youth, including children with special needs, have access to a medical home by providing medical home resources, technical assistance, and support to physicians, families, and other medical and non-medical providers who care for children.

Center for Medical Home Improvement
at the Crotched Mountain Foundation, Concord, New Hampshire, the site offers useful guides, tools, assessments, and other resources.

Digital Navigator
The Digital Navigator is a web-based software application that will help to guide patient care decisions, promote family and patient education, and support administrative functions to ensure successful implementation of the Patient and Family-Centered Medical Home model of care based on the 2011 NCQA Standards.

Joint Principles of the Patient-Centered Medical Home (PDF Document 37 KB)
A 2007 consensus statement from the AAP, AAFP, ACP, and AOA.

Patient-Centered Primary Care Collaborative
An organization of employers, physician organizations, trade associations, health benefits companies, and others advocating for wide-spread implementation of the patient-centered medical home.

Patient-Centered Medical Home Intro (Video)
Looking for a better approach to healthcare? Watch this 4-minute video about the Patient Centered Medical Home, from the Patient-Centered Primary Care Collaborative.

Building your Medical Home: An Introduction to Pediatric Primary Care Transformation (AAP)
A guide to building a medical home in practice, aimed at achieving recognition by the NCQA, from the American Academy of Pediatrics.

NCQA Patient-Centered Medical Home Recognition Program
A program of the National Committee on Quality Assurance to "recognize" practices as Medical Homes.

National Association for State Health Policy (NASHP)
An independent academy of state health policymakers, "dedicated to helping states achieve excellence in health policy and practice and providing a forum for constructive work across branches and agencies of state government on critical health issues." NASHP has sponsored a number of programs to support states in fostering and implementing medical homes.

Medical Home Literature
An extensive bibliography of Medical Home related publications.

For Parents and Patients

Family Voices
A national, nonprofit, family-led organization promoting quality health care for all children and youth, particularly those with special health care needs. Locate centers by state, F2F HICs (Family-to-Family Health Information Centers).

How to Partner with Your Physician (AAP)
Provides background information, links, and other resources, from the American Academy of Pediatrics' National Center for Medical Home Implementation.

Authors & Reviewers

Initial Publication: March 2008; Last Update: January 2015
Current Authors and Reviewers (click on name for bio):
Authors: Alfred N. Romeo, RN, PhD
Chuck Norlin, MD
Authoring history
(Limited detail is available on authoring dates before 2014.)
AAuthor; CAContributing Author; SASenior Author; RReviewer

Page Bibliography

American Academy of Pediatrics Medical Home Initiatives for Children With Special Needs Project Advisory Committee.
Policy statement: the Medical Home.
Pediatrics. 2004;113(5 Suppl):1545-7. PubMed abstract / Full Text

Cooley WC.
Providing a primary care medical home for children and youth with cerebral palsy.
Pediatrics. 2004;114(4):1106-13. PubMed abstract / Full Text

Council on Children with Disabilities.
Care coordination in the medical home: integrating health and related systems of care for children with special health care needs.
Pediatrics. 2005;116(5):1238-44. PubMed abstract / Full Text
AAP policy that helps primary care clinicians connect children and their families with appropriate services and resources in a coordinated effort to achieve good health.

McAllister JW, Presler E, Cooley WC.
Practice-based care coordination: a medical home essential.
Pediatrics. 2007;120(3):e723-33. PubMed abstract / Full Text

McPherson M, Arango P, Fox H, Lauver C, McManus M, Newacheck PW, Perrin JM, Shonkoff JP, Strickland B.
A new definition of children with special health care needs.
Pediatrics. 1998;102(1 Pt 1):137-40. PubMed abstract

Newacheck PW, Kim SE.
A national profile of health care utilization and expenditures for children with special health care needs.
Arch Pediatr Adolesc Med. 2005;159(1):10-7. PubMed abstract

Rushton FE Jr.
The pediatrician's role in community pediatrics.
Pediatrics. 2005;115(4):1092-4. PubMed abstract / Full Text

van Dyck PC, Kogan MD, McPherson MG, Weissman GR, Newacheck PW.
Prevalence and characteristics of children with special health care needs.
Arch Pediatr Adolesc Med. 2004;158(9):884-90. PubMed abstract