Promising Practice

Medical Home Community Team (MHCT)

State/Jurisdiction: Pennsylvania
Setting: Community
Population: CYSHCN
Topic Area: Access to Quality Healthcare Equity & Anti-Racism Safe and Connected Communities Care Coordination
NPMs: NPM 11: Medical Home

The Medical Home Community Team (MHCT) provides intensive, “home-grown” and high-quality home-visiting services to especially vulnerable and marginalized black and brown Philadelphian children and their families, centered on social determinants of health (SDoH) risks. The team works collaboratively with the referred child’s pediatric medical home and in equal partnership with MHCT families to address the impacts of racial and health inequities. MHCT uses an integrated, collaborative model, by directly engaging pediatric medical homes to identify and reach Philadelphia families with highly complex social-medical needs and who are most marginalized by inequitable systems in the provision of services (i.e., criminal justice, health care, child welfare systems, Supplemental Nutrition Assistance Program, Social Security Income). MHCT primarily serves black and brown parents and their children, with and without special healthcare needs, ages 0-21 years old in Philadelphia County. Since its inception, the MHCT has successfully served 80-100 Philadelphian families per year, often exceeding target goals. Family size of MHCT families is highly variable; a single parent household has on average, between 3-7 children. MHCT relevantly focuses on the association of medical health and SDoH in the children’s home environment, in coordination with the pediatric medical home. Services are dependent on the family’s need and can include individualized health education for every family member, coaching and skill-building, referrals to community-based organizations, linkages and coordination with behavioral health, mental health, and other social service and community organizations. The core components of MHCT include: ongoing collaboration with MCFH and the PA-AAP’s Medical Home Program (MHP), reciprocal partnerships with Philadelphia based pediatric medical homes to extend access and reach to especially vulnerable and marginalized black and brown families, uniquely tailored service provision to families experiencing racial and health inequities centered on social determinants of health (SDoH) risks, highly trained and prepared staff members, and investment in driving quality and trusted relationships with the referred child and family members.

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Implementation Handout

Health Promotion Council
LaMia Shaw, LSW, MPH

Practice Website