Medical Home Certification for Providers Serving Children and Youth with Special Health Care Needs: Recommendations on the process and criteria for certifying Medical Home providers in North Dakota
Confirmation E-mail address (optional):
Month / Year: Reported by:
1. Number of CSHCN identified this month? Total 4s - 5s 1s - 3s
2. Cumulative number of CSHCN identified to date?
3. Number of Care Plans developed with families this month?
4. How many times has the team met this month?? (if zero skip to question 6)
5. Please list the date(s) of those meetings and who attended? (fill in as many as you need only)
Date
Primary Care Provider Care Coordinator Nurse Clinic Administrator
Parents Other
Parent Other
7. Number of CSHCN identified this month?
8. Are there any areas that your team is struggling with that you would like advice or assistance from NDIS, its partners, or the other care teams?
Content Area Tested 1. community 2. care partnership support 3. delivery system design 4. decision support 5. clinical information system
How many days have you been testing change?
What did you learn?
Action Adjust Implement Discontinue
Action Adapt Adopt Abandon the change
