Medical Home Community Team (MHCT)

Full Description: Medical Home Community Team (MHCT) was established in 2017 through Title V funding from the Philadelphia Department of Public Health Division of Maternal, Child and Family Health in partnership with the Pennsylvania Chapter of the American Academy of Pediatrics’ Medical Home Program. MHCT is a “home-grown”, home-visiting program, offered by the Health Promotion Council (HPC), a non-profit 501(c)(3) organization. Since 2017, MHCT has addressed the needs of predominantly black and brown families across Philadelphia County with highly complex social-medical needs (children aged 0-21 from partnered pediatric medical home, with/out special healthcare needs) and most marginalized by inequitable systems in the provision of services. MHCT uses an integrated, collaborative model, by directly engaging pediatric and adult practices ongoing. MHCT relevantly co-locates the focus on medical health and social determinants of health (SDoH) in the family and child’s home environment in coordination with the pediatric medical home. Services are dependent on the family’s need and can include individualized health education, coaching and skill-building, referrals, linkages and coordination with behavioral health, mental health, and other social service and community organizations.
MHCT serves to directly diminish barriers by addressing, with intentional focus, the related SDoH, including healthcare and education access and quality, economic stability and emotional wellness, while navigating parenting in Philadelphia. MHCT ‘slows down’ with families, has them connect to their strengths and understand the situations present in the family home while identifying equity issues. As a critical component of our programming, MHCT values the quality connections developed during care coordination with families, medical homes and community partners. This working relationship builds on trust, openness and good communication which results in accessible and culturally effective service delivery for enrolled families. Over the last four years, MHCT has amassed countless experiences and lessons while providing home-visiting service in Philadelphia. The following is among the key lessons learned: Pivoting to virtual services during COVID-19 led to improved access and flexibility for MHCT clients. MHCT will continue to offer virtual services in the future; The home-visiting ecosystem is growingly competitive within Philadelphia. Funding is prioritized based on an ‘evidence based’ designation and leaves smaller, black and brown led programs competing for the limited funding left available; Many referral sources act as gatekeepers and may block access to quality programming because of bias and limited understanding of their client population. Research and evaluation is critical to maintaining funding or competing for new funding as every funder tends to desire their specific and demonstrated outcomes that are outside of an individual family’s success.

Abbreviated Description: Medical Home Community Team (MHCT) was established in 2017 through Title V funding from the Philadelphia Department of Public Health Division of Maternal, Child and Family Health in partnership with the Pennsylvania Chapter of the American Academy of Pediatrics’ Medical Home Program. MHCT is a home-visiting program, offered by the Health Promotion Council (HPC), a non-profit organization. MHCT has addressed the needs of families across Philadelphia County with highly complex social-medical needs (children aged 0-21 from partnered pediatric medical home, with/out special healthcare needs) and most marginalized by inequitable systems in the provision of services(i.e.child welfare, SSI). MHCT uses an integrated, collaborative model, by directly engaging pediatric and adult practices ongoing.