School of Public Health

Medical Homes in Idaho: 3 Lessons Learned

October 2016

Title V Maternal and Child Health Program | Division of Public Health

The Idaho Medical Home Demonstration project came to a crossroads in December 2015. Idaho first launched the project three years ago in partnership with the Medicaid Children’s Healthcare Improvement Collaborative (CHIC). The goal was to determine if a medical home coordinator could effectively introduce the patient-centered medical home model to family medicine and pediatric practices in rural communities and improve care for children with special health care needs. While the state’s Maternal and Child Health (MCH) Program funded the project, CHIC provided the quality improvement coaching and ongoing support to the medical home coordinators.

When the CHIC project ended, the MCH Program agreed to continue funding and technical assistance if the participating public health districts could find a way to provide the coaching and support. One of the districts, Eastern Idaho Public Health, took an innovative approach. The district leveraged in-house staff expertise from the Statewide Healthcare Innovation Plan (SHIP) to continue the demonstration and support the medical home coordinator.


Overall, the demonstration increased collaboration between primary care practices and local public health districts. It improved population health management and care coordination for complex and chronic health conditions among pediatric patients and established quality improvement projects, called ‘Learning Collaboratives,’ to improve clinic processes.

Since the transition to in-house staff support for medical home coordinators, the Eastern Idaho Public Health District has implemented developmental screening services, increased autism screening by 5% and depression screening by 15%.


1.) Choose a Medical Home Coordinator who is Flexible and Persistent. In the Idaho model, a single coordinator works with two to three clinics. The coordinator helps implement the pediatric medical home through quality improvement, patient education, referral coordination, and workflow management. It’s important for the coordinator to be flexible to meet the unique needs of the clinic and rural communities, and to take initiative and be persistent when working with clinics and families.

2.) Maintain Continuous Communication. The clinic and the medical home coordinator need to work together to understand the patient population and customize the coordination to patients needs.

3.) Conduct Readiness Assessments. Recruit clinics that value and are engaged in the project. To maximize success, potential participating clinics should be open to change and view medical home transformation as a path to improving the health of their patient population.


The Eastern Idaho Public Health District has two medical home coordinators currently serving two clinics—one rural and one urban—totaling 12 providers. Using the patient-centered medical home as the foundation, the clinics are focusing their efforts on improving care and screening related to depression, obesity, immunizations, autism, and developmental delays. These clinics have expressed the intention of hiring their own medical home coordinators to sustain their success once their participation in the project is over.

For more information about Idaho's Medical Homes Demonstration, please contact Jacquie Watson, MCH Program Manager, at