What is the Medical Home Leadership Network?

The Medical Home Leadership Network (MHLN) is a network of community and state leaders working to improve the health and well being of children and youth with or at risk for special health care needs and their families.   The Washington State Medical Home Partnerships Project for Children and Youth with Special Health Care Needs (MHPP) at the University of Washington helps connect and support these efforts through funding from the Washington State Department of Health (DOH), Children with Special Health Care Needs Program.

Our focus is the patient-centered primary care “medical home” and supporting robust connections and communication between primary care and the family and the specialty and community services.

We bring together diverse community leaders to identify and build on local strengths in order to:

  • increase the number of children and youth with, or at risk for special health care needs, receiving comprehensive care through a medical home
  • increase the number of young children receiving developmental screening, whether in their primary care provider’s office or a community setting

The MHLN is composed of:

  • Volunteer, interdisciplinary parent-professional teams  and coalitions based in counties across the state
  • Project staff from the Medical Home Partnerships Project at the University of WA, Center on Human Development and Disability
  • A broad range of organizational partners


County MHLN teams typically include:

  • Pediatrician or family physician experienced in the care of children with disabilities and chronic health conditions
  • Parent of a child with special needs
  • Public health nurse, usually the Children with Special Health Care Needs Coordinator for the county
  • Early Intervention Family Resources Coordinator
  • Community service partners such as schools, oral health, mental health etc.

There are also two-clinic based MHLN teams in King County focused on improving coordinated and culturally sensitive services to their patients and families- Odessa Brown Children’s Clinic and Harborview Pediatrics, both in Seattle.

Team members are experienced at taking care of children with special health care needs and knowledgeable about practical aspects of implementing medical homes.


Many MHLN County Teams have expanded to become community-based coalitions focusing on improving:

  1. increased access to developmental screening, diagnostic services, treatment and family support for children with Autism Spectrum Disorder (ASD) or developmental disabilities or
  2. increased access to developmental screening and referral to 0-3 services

Teams have done this through a MHPP/DOH facilitated or self-realized Community Asset Mapping process.  Funding and support from DOH’s AS3D grant (2016-2019) has supported expansion of new CAM coalitions in Greater Grays Harbor (Grays Harbor, Mason and North Pacific Counties), Pacific, Cowlitz and Chelan and Douglas Counties.

There are currently 18 teams and coalitions with over 150 members, covering 21 of the state’s 39 counties and the majority of the state’s population. In addition, a  number of counties have individual representatives in the Network, but do not currently participate as a team.

Examples of team activities include:

  • Identifying/developing resource lists of community services need by children and youth with special health care needs
  • Participating in  Community Asset Mapping coalitions to improve early identification and diagnosis of children with autism and other developmental disabilities ( Community Asset Mapping (CAM) E-Update )
  • Developing interdisciplinary School-Medical-Autism-Review Teams (SMART) to provide community-based autism evaluation and diagnosis close to home for families
  • Distributing Child Health Notes to community primary care providers and other service providers to increase awareness of specific care management issues for children with special needs and community and state resources available to help
  • Building on the work of the Pediatric Transforming Clinical Practice Initiative (P-TCPi) to help primary care, specialty care and community partners transition to improved care for children and population and value-based payment for clinicians.
  • Collaborating with community partners to increase the use of standardized developmental screening tools that identify young children with developmental disabilities and delays. In some communities, this is participating in Great MINDS (Medical Homes Include Development Screening) training of primary care practices in the use of developmental screening tools and how to link families with early intervention and community resources.
  • Piloting care coordination strategies within team clinics such as allowing longer appointments for children identified as having complex care needs, using clinic data to identify patients in need of specific services, and developing a single emergency care plan to be used by patients and all their health care providers.
  • Presentations to primary care practices and others with practical tips for providing care through the model home model, including what community resources are available for children with special needs and how to access them
  • Spearheading community-wide efforts to provide coordinated services for children and youth with special needs
  • Sharing expertise with state policymakers about state programs that impact care for children with special needs, their families, and health care providers
  • Piloting a Family Advisory Group within a pediatric practice
  • Informal consultation with colleagues
  • Developing grants to support and build on team-related activities

Interested in Learning More?  

Contact Kate Orville, MPH, Co-Director MHPP orville@uw.edu

Project Staff

Medical Home Partnerships Project staff and colleagues at the University of Washington, Center on Human Development and Disability are available to provide or identify and facilitate other technical assistance to MHLN teams.


It is a national and Washington State public health goal for every child and youth with special health care needs to have access to a medical home. A broad range of partners support the work of the Medical Home Leadership Network. The Washington State Department of Health, Children with Special Health Care Needs Program has provided core funding since the MHLN began in 1994. Additional funding and support has come from the US Maternal and Child Health Bureau, the American Academy of Pediatrics, the WA Early Support for Infants and Toddlers Program (ESIT) as well countless hours of volunteer time from community team members and other supporters.