National Resources

National Resource Center for Patient/family-Centered Medical Home – AAP

The National Resource Center for Patient/Family-Centered Medical Home is a national technical assistance center focused on improving the health and well-being of, and strengthening the system of services for, children and youth with special health care needs and their families by enhancing the patient/family-centered medical home. This web site provides tools, resources, state specific information, and promising practices in patient/family-centered medical home implementation.

National Center for Quality Assurance (NCQA)

NCQA’s Patient-Centered Medical Home (PCMH) Recognition program is the most widely adopted PCMH evaluation program in the country. Approximately 13,000 practices (with 67,000 clinicians) are recognized by NCQA. More than 100 payers support NCQA Recognition through financial incentives or coaching.

 Agency for Healthcare Research and Quality (AHRQ) Patient Centered Medical Home Resource Center

The Agency for Healthcare Research and Quality recognizes that revitalizing the Nation’s primary care system is foundational to achieving high-quality, accessible, efficient health care for all Americans. Here you will find 5 Key Function and Attributes of the Medical Home, Foundational Supports for the PCMH Model, and Practice Facilitation resources

Patient-Centered Primary Care Collaborative (PCPCC)

The Patient-Centered Primary Care Collaborative (PCPCC) is and will position itself as an advocacy organization—a coalition that serves as a “driver of change,” educating and advocating for ideas, concepts, policies, and programs that advance the goals of high-performing primary care as the foundation of our health care system.

American Academy of Family Physicians (AAFP)

The American Academy of Family Physicians defines a medical home as one that is based on the Joint Principles of the Patient-Centered Medical Home (PCMH)(3 page PDF), the Shared Principles of Primary Care(, and the five key functions of advanced primary care. No matter where you fall on the spectrum of practice improvement—managing current projects, enhancing basic concepts, or advancing to more complex initiatives—the adoption of the five functions can benefit your practice, your patients, and your bottom line.

NJAAP Warmline

Call 609-842-0014 and ask for Michael Stec, MBA, PCMH CCE or Lindsay Caporrino, PCMH CCE anytime for assistance with:

  • NCQA PCMH Recognition website navigation, tools and resources
  • Eligibility and readiness assessment
  • PCMH Standards and Guideline questions
  • Document Review
For Providers

Care Coordination

Care Coordination in a Statewide System of Care - Catalyst Center-National Center for Health Insurance and Financing for Children and Youth with Special Health Care Needs

Financing Care Coordination - Catalyst Center-National Center for Health Insurance and Financing for Children and Youth with Special Health Care Needs

New Jersey Institute for Disabilities

Care Planning

5 Numbers to Remember About Early Childhood Development – Center on the Developing Child, Harvard University

Standards for Systems of Care for Children and Youth with Special Health Care Needs Version 2.0 - Association of Maternal & Child Health Programs (AMCHP) & National Academy for State Health Policy (NASHP)

Team-based Care

Best Practices & Tools / HeartBeat Free Newsletter - Language of Caring

Guiding Principles for Team-Based Pediatric Care – Policy Statement, American Academy of Pediatrics (AAP)

Family-Centered Care Assessment Tool for Providers (permission for use is required from National Center for Family-Professional Partnerships)

Picker Institute - Institute for Patient- And Family-Centered Care

Roles and Functions of Community Health Workers in Primary Care  – Annals of Family Medicine

What a Medical Assistant Can Do for Your Practice – Family Practice Management, American Academy of Family Physicians (AAFP)

Transition to Adult Care

Got TransitionTM – Center for Health Care Transition Improvement (Six Core Elements of Health Care Transition 2.0)

Transition to Adulthood – SPAN Parent Advocacy Network

For Families
System Integration Academy Initiative


This initiative was funded through September 2017. Please read below for information on the project goals and resources, and click  to view the National Academy for State Health Policy's (NASHP) June 2018 report that highlights the successful efforts of New Jersey and 15 other states to advance medical homes for CYSCHN and promote system integration.

Shared Plan of Care (SPoC) [English / Spanish]

SPoC Adult Guide to Complete [English / Spanish]

SPoC Youth Guide to Complete [English / Spanish]