CSHCN Medical Home

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What is a Medical Home?

A medical home is not a building – it is a family-centered approach to comprehensive care that is a partnership between a child, the child’s family and the child’s primary health care setting. Through this partnership, a family works with health care experts to find and access the medical and non-medical services that the child needs.

Receiving care through a medical home can improve a child’s health and make life easier for the child’s family. A medical home care team can include doctors and nurses, therapists, dentists, pharmacists, community health workers, school staff, friends, neighbors and anyone else who cares for your child.

Components of a Medical Home

  • Accessible – services are provided within the child’s and family’s community and someone is able to help the child 24 hours a day, 7 days a week.
  • Family-Centered Care – the family is recognized as the expert in the child’s care and is a valued member of the care team who contributes to decision making.
  • Continuous Care – the child is able to see the same pediatric health care professionals over time and are supported during the transition to adulthood.
  • Comprehensive Care – the child’s care includes check-ups and preventative care, primary care and specialty care. The child and family are connected to support and education opportunities.
  • Coordinated Care – the child’s care team works with multiple providers and the family to develop a plan of care, book appointments, handle referrals and provide access to resources in the community.
  • Compassionate Care – the medical home care team are genuinely concerned about the overall wellbeing of the child and family
  • Culturally Competent Care – services are delivered in the child’s and family’s preferred language and the care team respects the family’s cultural and religious beliefs.  

Joint Principles of the Patient-Centered Medical Home

On November 10, 2008, the American Medical Association (AMA) voted to adopt the "Joint Principles of the Patient-Centered Medical Home," joining the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians and the American Osteopathic Association in endorsing the principles.  

The key elements of the medical home are based on recognized standards of child and adolescent health care. They are documented in policies and best practice guidelines by recognized professional organizations, such as the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP).

A more thorough definition from these and other professional organizations includes the physician-patient relationship, quality of health care, infrastructure, and payment system that will result from ongoing, comprehensive, cost-efficient, and effective health services.

Medical Home Brochures

The Maternal & Child Health Section developed brochures to help families and providers understand the importance of the medical home model. To order brochures, please use our online order form.  

Genetics Resources

  • The Mountain State Regional Genetics Network
    The Mountain State Regional Genetics Network is one of seven regional networks covering the nation. The purpose of the network is to help families connect to genetic services and resources. The network also strives to help providers better understand available services so that they are comfortable making referrals for genetic testing. 

Free Continuing Education (CE) Courses

Texas Health Steps’ award-winning online education program offers free CE courses for primary care providers and other health professionals. These courses offer updated clinical, regulatory and best practice guidelines for a range of preventative health, oral health, mental health and case management topics, including medical home.

Additional Medical Home Resources

  • The National Center for Medical Home Implementation (NCMHI) publishes comprehensive resources on medical home for a variety of stakeholders. The NCMHI also provides support, training and technical assistance to medical practices, clinicians, families, and communities.
  • The Texas Parent to Parent Medical Home Toolkit explains what a medical home is and how to get one.
  • Navigate Life Texas includes tips for families including how to work with your child’s doctor to create a medical home
  • Texas Medical Home Initiative is a nonprofit, practitioner led organization whose mission is to promote the Patient-Centered Medical Home Model of care in Texas.
  • AMCHP National Standards for Systems of Care for CYSHCN
    The Association of Maternal & Child Health Programs just released a new interactive website for the National Standards for Systems of Care for Children and Youth with Special Health Care Needs, Version 2.0. This tool strives to serve the nation’s 14.2 million children and youth with special health care needs. Version 2.0 of the National Standards for Systems of Care for Children and Youth with Special Health Care Needs sets the core components for the structure and process of effective systems of care while streamlining content for easier use by states and stakeholders. Visit the website here: http://cyshcnstandards.amchp.org/app-national-standards/#/
  • Cultural and Linguistic Competence Health Practitioner Assessment
  • The National Center for Cultural Competence has developed a self-guided tool to improve delivery of culturally competent services for diverse populations. Clinicians who complete the self-assessment will receive a report with professional development and educational resources related to cultural and linguistic competence.   

    View the tool  

The Texas Department of State Health Services does not endorse external links to other websites. These links are informational and may not be accessible to persons with disabilities. For more information about Children with Special Health Care Needs, Title V Maternal and Child Health or information regarding maternal and child health in Texas, please email TitleV@dshs.texas.gov or call (512) 776-7373.

Last updated February 25, 2021