What is the Medical Home Leadership Network?

The purpose of the Medical Home Leadership Network (MHLN) is to 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 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.

Team members are experienced at taking care of children with special health care needs and knowledgeable about practical aspects of implementing medical homes. There are currently 14 active teams with over 85 members, covering 15 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.

While teams do not provide care to individual children as part of their work with the MHLN, they do identify and carry out activities to address one or more unmet medical home needs in their county. See the MHPP E-Updates for more information about Medical Home team and Community Asset Mapping coalition work.

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 )
  • 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
  • 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

Project Staff

Medical Home Partnerships Project staff and colleagues at the University of Washington, Center on Human Development and Disability are available to provide 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.


The Medical Home Leadership Network began in 1994 as a collaborative effort between the Center on Human Development and Disability, Seattle Children’s Hospital, the Washington Chapter of the Academy of Pediatrics, and the Washington State Department of Health, Children with Special Health Care Needs (CSHCN) Program.

Initial funding came from the Department of Health CSHCN Program and the US Maternal and Child Health Bureau for a demonstration project to provide training and support to physicians and public health nurses who served children with special health care needs. Additional funding was later provided by the Washington State Early Support for Infants and Toddlers to add Family Resources Coordinators and parents to the teams. Initially called the Medical Home Training and Resource Project, the name was changed to the Medical Home Leadership Network (MHLN) in 2000, and then later to the Medical Home Partnerships Project.

The MHPP has continued through ongoing support and funding from the Department of Health’s Office of Healthy Communities, including the Healthy Starts and Transition Unit (which includes the Children with Special Health Care Needs Program).

Additional funding has come from federal grants awarded to the state Department of Health, including:

Great MINDS (Medical Homes Include Developmental Screening) Grant (2011-2014) (2014- ongoing support from Rural Health and other sources)
The WA Department of Health received a 3 year federal HRSA grant to improve systems of care for children and youth with special health care needs and their families. The grant did this by improving medical homes through pairing parents and physicians to give continuing education to providers, continuing an innovative Community Asset Mapping process (piloted in our state’s  federal autism grants), and working to improve developmental screening in WA.

DOH has contracted with the Medical Home Partnerships Project the WA Chapter of the American Academy of Pediatrics (WCAAP), and state family organizations (Parent to Parent, the Family to Family Health Information Center at PAVE, the Fathers’ Network, and the Center for Children with Special Needs) to closely collaborate with DOH on this  initiative. The WCAAP had the primary responsibility for developing and implementing the training piece which focused on medical homes, family-centered care and developmental screening. WCAAP trustees delivered the training with parent co-presenters.  MHPP staff and local MHLN teams helped with these efforts, in addition to consulting on the training modules and strategies.

Great MINDS Grant Abstract

Great LINCS (Links to Integrate and Coordinate Services for CYSHCN)

The Medical Home Partnerships Project is collaborating on a federal care coordination grant received by the Washington State Department of Health,  Healthy Starts and Transition Unit (which includes the Children with Special Health Care Needs Program). The grant runs September 2014-2017.


  1. Engage partners in refining a course of action to achieve systems integration through improved care coordination in a medical home for CYSHCN.
  2. Participate in quality improvement and collaborative innovation through a cross state learning community.
  3. Expand the capacity of WithinReach as a statewide shared resource to support coordinated systems of services for CYSHCN.
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