What is the Medical Home Initiative?




The Medical Home Initiative serves children with special health care needs or those at risk. Special health care needs are any chronic physical, developmental, behavioral or emotional condition that requires any health care that is greater than what typical children require.

Our office works with those living in the Southwest Region of Connecticut from ages 0-21 years. The team is comprised of a physician champion who serves as the director, a pediatric nurse practitioner and a licensed clinical social worker who serve as care coordinators. A Care Coordinator is a skilled professional (social worker or nurse practitioner) who will work closely with you and will make all efforts to assist you and your child in accessing services to meet his or her special needs. This includes information about medical, educational, social, and recreational resources in your community; including, but not limited to, the 211 Infoline, summer camps and after-school programs.

Children & Youth with Special Health Care Needs (CYSHCN) are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and require health and related services beyond that required for children in general. In 2018, Data Resource Center for Child & Adolescent Health estimated that there were approximately 138,665 CYSHCN in Connecticut.

Communities that the Southwest Region of the Medical Home Initiative Serves:


Southwest Region Map (*)

  • Bridgeport
  • Darien
  • Easton
  • Fairfield
  • Greenwich
  • Monroe
  • New Canaan
  • Norwalk
  • Stamford
  • Stratford
  • Trumbull
  • Weston
  • Westport
  • Wilton


The mission of the Connecticut Department of Public Health is to protect and improve the health and safety of the people of Connecticut. It advocates for physical and mental health, prevents disease, injury and disability, and promotes a healthy and sustainable environment for the people. Learn more at Connecticut Department of Public Health

The Cohen Children’s Institute brings skilled pediatric specialists to our community with the purpose of catering to your children’s unique needs.  Learn more at Cohen Children's Specialty Center (stamfordhealth.org)

The mission of OPTIMUS is to serve as the patient-centered medical home for the communities to achieve and maintain a positive state of wellness, particularly for the uninsured and underserved. Learn more at OPTIMUS Health Care – Southwestern Connecticut’s largest provider of primary health care services.

Stamford Children’s Health Collaborative links community resources and facilitates support to improve the overall health and wellness of children. The 3-branches of the Stamford Children’s Health Collaborative are nutrition, physical activity and socio-emotional health. Learn more at Stamford Children's Health Collaborative (stamfordhealth.org)

Community Health Center, Inc. offers comprehensive primary medical care for adults and children, dental care, school-based health services, behavioral health services, gynecological care as well as family planning.  Learn more at Home (chc1.com)

FAVOR, Inc. is a statewide organization that is committed to empowering families as advocates and partners in improving educational and health outcomes for children. FAVOR offers a single place for families with children who have medical, mental, emotional, and behavioral health challenges find information, assistance and training. Learn more at Favor Connecticut (favor-ct.org)

The Child Guidance Center of Southern Connecticut is dedicated to improving the mental and behavioral health of children from birth to 18, through treatment, education, and community support in Stamford, Greenwich, Darien and New Canaan, Connecticut. Learn more at The Child Guidance Center of Southern Connecticut (childguidancect.org)

Family Centers offers education, health and human services to children, adults and families in Fairfield County. Their network of health, education and human service programs give individuals and families the tools needed to establish a strong educational foundation, overcome complex and critical problems, carry on healthy productive lives and achieve personal improvement. Learn more at Family Centers - landing page

Person to Person provides individuals and families with assistance for basic needs such as food, clothing, financial assistance, and household necessities to help overcome daily challenges and improve their lives. Learn more at Home - Person to Person (p2phelps.org)

The Vita Health & Wellness Partnership is a network of local agencies working collectively to help residents throughout the community be as healthy as possible by expanding access to medical and mental health care, linking education with social services, and improving access to substance abuse prevention and treatment. Learn more at https://vitastamford.com/

United Way is dedicated to help hard-working, struggling families by focusing on increasing access to affordable, quality care and education, increasing access to fresh, healthy food and giving people tools to help them save and become more financially stable. Learn more at United Way of Western Connecticut | (uwwesternct.org)

The Center for Immigrant Opportunity brings passionate people together to help immigrants and their families succeed in the community. Learn more at Home - Building One Community (building1community.org)

SPEF is committed to fostering relationships within the school district, corporate community, and city of Stamford to support and strengthen the public education system with funding, programming, and volunteers. Learn more at Stamford Public Education Foundation – Stamford Public Education Foundation (spefct.org)

Connecticut Parent Advocacy Center, Inc. (CPAC) is a statewide nonprofit organization that offers information and support to families of children with any disability or chronic illness, from birth through 26 year of age. Learn more at Connecticut Parent Advocacy Center - CPAC (cpacinc.org)

The Mayor's Youth Employment Program is to provide Stamford's youth with the necessary job readiness and leadership skills needed to compete in the global workforce. Learn more at The Mayor's Youth Employment Program (stamfordmyep.com)


    • Autism, Asthma, ADHD, Behavioral health
    • Transition from Peds to Adults - Youth with Special Health Care Needs (ct.gov) – DPH website
    • Durable Medical Equipment - NEAT Center
    • Dental
    • Healthy Living (Obesity/BMI) - Attached bookmarks and handouts.
    • 211 Connecticut
    • Child Development Infoline
    • Diapers
    • ESL Classes
    • Clothing – Person 2 Person, Clothes to Kids
    • Transportation
    • Free tutoring/after school programs
    • Insurance – HUSKY; Access Health; Office of the Healthcare Advocate
    • Legal – Center for Children’s Advocacy
    • Charter Oak
    • Family Shelters
    • 211 Connecticut
    • Food banks
    • DSS
    • Farmers markets
    • WIC
  • JOBS
    • Local Employment Service centers
    • CTFSN
    • PATH
    • St. Joseph’s Parenting Center

    Connecticut Medical Home Initiative at FAVOR, Inc. can provide information on respite funds and extended services.  They can be reached by calling 860.436.6544 or toll free at 1.855.436.6544.

    Respite is planned or emergency temporary relief that can be offered once or multiple times to family caregivers who are caring for individuals with special needs such as a disability or chronic or terminal illness. Please note that due to the limited availability of funds, there is a $500 per family maximum per year for Respite funds, including camp within the availability of funds.

    Source: Department of Public Health - Children & Youth with Special Health Care Needs and Connecticut's Medical Home Initiative



Medical Home Initiative,  Southwest CT
For Children & Youth with Special Health Care Needs

1351 Washington Boulevard – 4th Floor
Stamford, CT 06902

Tel: 203.276.7552
Toll Free: 866.239.3907
Fax: 203.276.2134
Email: [email protected]

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