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									                                                     Medical Home Tools

Community
   Community for All Toolkit:
    www.cincinnatichildrens.org/svc/alpha/c/special-needs/resources/
    The Center for Infants and Children with Special Needs at Cincinnati Children's Hospital Medical Center has created an extensive, one-stop
    resource directory to assist caregivers of children with specialized health care needs. The goal of the directory is to provide comprehensive
    web-based information -- assembled in one convenient location -- to both parents and professionals. The resource directory is designed to be a
    quick, easy reference for all parents and medical professionals, regardless of previous computer experience.
   Sample Community Resource Roadmaps: www.waisman.wisc.edu/cshcn/Dane.pdf
    A quick guide for navigating community resources in your county for children with special health care needs. Developed by the Regional
    Center for Children With Special Health Care Needs - a component of the Wisconsin Title V Program.
Health Care Organization
   Crosswalk to Reimbursement:
    http://www.medicalhomeinfo.org/tools/Coding/Crosswalk%20-%20Final.doc This reimbursement tool identifies the range of relevant codes
    that could be used to finance components of a medical home and contains an index of medical home codes and selected vignettes.
   ICD-9 Codes for CYSHCN: (Attached)
Care Partnership Support
   Comprehensive Care Planning: http://www.medicalhomeinfo.org/tools/CarePlans/ComprehensiveCarePlanningII.pdf
    This packet contains information about the essentials of comprehensive care planning for children with special health care needs (CSHCN).
    Three distinct types of documents present medical information plans, emergency plans, and working (action) care plans. When combined
    appropriately for CSHCN (based upon need), these tools make up a comprehensive care plan. From the National Medical Home Learning
    Collaborative-I.
   Care Coordination Toolkit: http://www.medicalhomeinfo.org/tools/Tools/care%20%20coord%20toolkit.pdf
    Proper use of coordination of care codes with CSHCN. This toolkit provides information on billing for the coordination of care with
    descriptions of individual codes, proper documentation, and an easy to follow billing slip. Developed by the Center for Infants and Children
    with Special Needs at Cincinnati Children’s Hospital Medical Center & The National Center of Medical Home Initiatives for Children with
    Special Needs.
   Sample Practice-based Care Coordination Job Description:
    http://www.medicalhomeinfo.org/tools/Downloads/Job%20Descriptions/MA%20Care%20Coordination%20Job%20Descriptions.doc Social
    Work, case management, public benefits and resource expertise; tasks primarily social, not medical.
   Sample Parent Consultant Job Description:
                                                        Medical Home Tools

    http://www.medicalhomeinfo.org/tools/Downloads/Job%20Descriptions/Pediatric%20Practice%20Enhancement%20Project%20Parent%20C
    onsultant%20Job%20Description.doc Parent Consultant - will be a parent of a child with SHCN, preferably with experience and/or comfort
    working in a medical setting.
   Parent Partner Guide: http://www.medicalhomeimprovement.org/assets/pdf/CMHI_PP_Guide.pdf
    A guide for parent and practice “partners” working to build Medical Homes for CYSHCN.
   Websites for Families with CSHCN (Attached). An example of a resource sheet of websites.
Delivery System Design
   Promoting Cultural Diversity and Cultural Competency Checklist: http://gucchd.georgetown.edu/nccc/nccc7.html A self-assessment checklist
    for personnel providing services and supports to CYSHCN and their families. This checklist is intended to heighten the awareness and
    sensitivity of personnel to the importance of cultural diversity and cultural competence in human service settings. It provides concrete
    examples of the kinds of values and practices that foster such an environment.
   Improving Cultural Competency in Children’s Health Care: http://www.nichq.org/ A booklet outlining key changes and measures, as well as additional key
    resources related to improving cultural competency in the care of children.


Decision Support
   Medical Home Referral Faxback Form: http://www.medicalhomeinfo.org/tools/Documentation/PA-
    Referral%20Fax%20Back%20Form.doc
   Medical Home Sample Progress Note: http://www.medicalhomeinfo.org/states/Downloads/PA%20Info/Progress%20Note.doc Developed
    by the Pennsylvania Medical Home Team.
   Medical Home Documentation Guidelines:
    http://www.medicalhomeinfo.org/states/Downloads/PA%20Info/Documentation%20Guidelines.doc When caring for CSHCN, the use of a
    standardized progress note may be helpful to document the increased information necessary to deliver care. The appropriate documentation
    will help justify the Evaluation and Management codes billed for each encounter. The progress note attached to these guidelines is one
    template that can be used to provide the necessary documentation for the E&M codes that are billed for this population. Developed by the
    Pennsylvania Medical Home Team.
   Primary Specialty Collaboration: http://gucchd.georgetown.edu/files/products_publications/PrimarySpecialityCollaboration.pdf Enhancing
    collaboration between primary and subspecialty care providers for CSHCN.
Clinical Information System
   CYSHCN Complexity Scoring Scale: http://www.medicalhomeinfo.org/tools/Tools/complexity.doc

								
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