Pediatric Medical Home

UCLA Health approach to coordinated pediatric care

Through the UCLA Health Pediatric Medical Home Program, our team has revolutionized care for children with chronic disease and complex health needs. Using a groundbreaking approach, we bring together every member of your child’s care team to ensure you receive the highest level of coordinated care.

By improving communication among health professionals and family members, we aim to enhance the overall well-being of our patients. When you come to us, you’ll find:

Accessible, convenient care: As your child’s “home base,” we offer coordinated support in one location. Our goal is to help you navigate your child’s care and ensure that checkups, tests and treatments are more convenient. With a strong focus on accessible care, our team speaks several languages, and we’re always available to answer your questions and offer support.

Holistic, family-centered approach: We understand the challenges that often affect families of children with special needs. That’s why our services extend beyond medical treatments. Our experienced, compassionate team comes together to focus on your child as a whole person. We deliver services, support and solutions to your entire family while keeping your child’s health needs front and center.

Dedicated team of experts: Your child receives care from board-certified doctors who specialize in pediatrics. A knowledgeable family liaison offers you and your family advice and support. Our team orchestrates everything from medications and visits with specialists to social services and school support.

Improved health and fewer complications: Our comprehensive approach cuts ER visits by 50%. By coordinating care, addressing issues as they arise and helping you manage medications and therapies, we work with you to get necessary care at the right time. As a team, we improve your child’s health and enhance your family’s well-being.

Our services

At UCLA Health, we designed our Pediatric Medical Home Program around your family’s needs. Every member of our team is passionate about delivering timely, effective care while guiding and supporting your family along the way. Customized services are at the core of our program. We offer:

Coordinated care and support

We focus on the whole child and work with your family to coordinate the care and services you need. A dedicated family liaison is by your side to serve as your main point of contact and answer your questions. We work with you to:

• Address any issues your family may have, including domestic concerns, challenges at school or questions about mental health
• Arrange home health care, therapy and other services
• Ensure every member of your child’s care team is on the same page and follows the same treatment plan
• Guide you through the health care system and help you navigate all aspects of your child’s care
• Manage medications and refills
• Offer patient education, resources and support as needed
• Schedule tests, procedures, surgeries and other appointments with specialists

Parent Advisory Group

Our Parent Advisory Group aims to make our services as effective as possible and address the specific needs of children and family members. The group meets once a month and all parents in the UCLA Health Pediatric Medical Home Program are welcome to attend. Parents and caregivers share their knowledge, experiences and resources with the group while learning from others.

During each meeting, an agency or community organization presents information about a topic related to children with special health care needs. Subjects include:

• Emergency preparedness for people with special medical needs
• Health and wellness for the whole family
• Special education services, 504 plans and Individualized Education Programs (IEPs)
• Stress management techniques

The Parent Advisory Group also provides the UCLA Health Pediatric Medical Home Program with invaluable feedback and recommendations. Our specialists consult parents and gain essential information about how to improve the program. We aim to offer services that are practical, helpful and customized.

Frequently asked questions

What is the Medical Home Program?

The Medical Home is not a facility or structure — no one lives in our "home.” It is a program based at the UCLA Mattel Children's Hospital. The program helps families with chronically ill children navigate the complicated health care system. 

Who is on the Medical Home team?

Our Pediatric Medical Home team includes:

Family liaisons: Our family liaisons help coordinate care for our Medical Home patients and facilitate communication with the UCLA Health medical team. We have three full-time family liaisons available during office hours to answer questions about care coordination. Our family liaisons also help coordinate follow-up appointments and procedures. All of our family liaisons are native Spanish speakers.

Resident doctors: A pediatric resident doctor is a physician who has finished four years of medical school and is currently getting additional training in the care of infants, children and adolescents. Each patient is assigned to a resident who will be the "primary doctor" or "general pediatrician."

Attending doctors: A pediatric attending doctor has finished three years of additional training in pediatrics. They guide and train the pediatric resident doctor during clinic appointments. The attending doctor serves as the resident doctor’s supervisor and is ultimately responsible for medical decisions and treatments. Many attending doctors work closely with the resident doctor to care for your child.

Specialty care doctors: A specialty care doctor is an attending doctor who has finished an additional two or three years of training. The additional training focuses on a specific body system, age group or technique to diagnose or treat disorders and diseases. Specialty care doctors communicate with the resident doctor, attending doctor and parents to create an appropriate treatment plan for the patient.

What does it mean to be a Medical Home patient?

Medical Home patients receive care from a resident doctor and attending doctor. These physicians work together to provide coordinated care. Appointments with these doctors may last longer than a typical office visit.

Each patient receives a family notebook called the "All About Me" binder. The family maintains this binder, which is a portable medical record. It contains the patient’s medical history, medication list, physician names and contact information. Our team connects Medical Home families to organizations that support every stage of the child's growth and development.

What are the responsibilities of Medical Home parents?

Parents are responsible for managing their child's medical care and appointments. They maintain the "All About Me" binder and present it at all appointments. Parents also bring their child’s most recent immunization card and current medication list, as well as insurance cards and letters from insurance companies.

Parents also agree to attend all appointments as scheduled or notify the family liaison as soon as possible when unable to attend. Any patient who misses multiple appointments may be referred for a social work consultation and may be unenrolled from the Medical Home Program.

Can anyone be part of the Pediatric Medical Home Program?

We use certain criteria to determine if a patient will benefit from our program. We have a waiting list for enrollment, but we are open to new referrals. If you’re interested in joining the Pediatric Medical Home Program, please complete a referral form.

Meet our team

Our team includes family liaisons, social workers, nurses and doctors who specialize in pediatrics and adolescent medicine. We work closely with your child’s entire care team and coordinate with specialists, therapists and pharmacists.