Tanisha kept a tally on the back of an envelope of which practices answered the phone before voicemail. Eleven calls in two days. Eleven different scripts. The first ten said something like, “we’ll have to discuss that with the doctor and call you back.” Nobody called back. Practice eleven said yes within thirty seconds and offered a meet-and-greet for the following Tuesday. We do not normally tell families to celebrate the eleventh phone call. We are telling you now.

A medical home is a relationship, not a building.

The phrase comes from pediatrics. The Academy of Pediatrics popularized it in the nineties to describe a primary-care practice that knows your kid, holds the file, coordinates the specialists, and answers the phone in a crisis. It is a good idea. It works. It also, somewhere around age twenty-one, evaporates. Pediatric practices age out. Adult practices, if you can find one, treat your adult like a stranger every visit. Specialists send results to whichever office referred them most recently. The chart fragments. The passport gets lost. You become the chart.

The medical home for an autistic adult, then, is not a building you locate on a list. It is a relationship you build with one practice, one clinician, and one front desk. Brick and mortar do not matter. The phone tree matters. The scheduler matters. The clinician’s willingness to schedule forty minutes when the protocol says twenty matters most.

The three-call screen.

Pick three practices on your insurance panel. Call them in one sitting. Ask each the same three questions, in the same order, with the same words. Are you accepting new adult patients aged twenty-one and up. Can a visit be scheduled at forty minutes instead of twenty. Will you read a one-page medical passport before vitals. Note the answer. Note the tone. Note who pivots to a manager and who pivots to a no.

Trust the practice that says yes without asking what is wrong with your adult. Trust the practice that asks instead what your adult needs to feel safe. The two practices look almost identical from the website. They look nothing alike on the phone.

The meet-and-greet decides everything.

Once you have a candidate, ask for a no-exam meet-and-greet. Many adult practices will schedule one if you ask. Some bill it as a wellness visit. Some do not bill at all. Either way, you walk in without a presenting complaint, sit in the room, hand the doctor the passport, and watch him read it. If he reads it in silence and asks one good question, you have a doctor. If he flips through it like a menu and starts the visit with “so what brings you in,” you have a problem.

Bring the passport in two formats. Printed on heavy paper for the chart. Sent ahead of the visit by patient-portal message so the practice has it in writing. The doctor either reads it ahead of time, which tells you something, or he does not, which tells you something else.

Make the passport part of the chart.

The hardest part of an adult medical home is continuity. Front-desk staff turn over. Doctors leave practices. Practices get acquired. The passport, scanned into the EHR and tagged as a clinical document, is what survives the turnover. Ask the practice to do this in writing. Most modern EHRs have a “patient instructions” or “care plan” tab. The passport belongs there. Tell them where you want it. Tell them why.

If they refuse, the refusal is information. A practice that will not file a one-page accommodation document into your adult’s chart is telling you that the next visit will start where the last one ended. Which is to say, nowhere.

What good states do that Michigan does not.

Massachusetts and Pennsylvania both fund care coordinators inside their adult disability service systems whose job, in part, is to help families locate primary-care practices that will take adults with autism. Wisconsin’s Family Care managed long-term services and supports model includes care coordination. Vermont and Oregon have piloted adult medical home grants specifically targeting populations like ours. Michigan funds none of this through its Prepaid Inpatient Health Plans. Families do this work themselves, on the back of an envelope, eleven calls at a time. None of this was inevitable. Other states made different choices. Michigan didn’t.

Your assignment this week.

Pull your insurance directory. Pick three practices. Run the three-call screen. Score each call. The next morning, write a single email to the practice that scored highest, request a meet-and-greet, attach the passport, and ask for a written accommodation note in reply. That is your week. If practice number one falls through, run the screen again next week with three more practices. If practice number eleven is the one that says yes, drive to the meet-and-greet anyway. Tanisha did. So can you.

The medical home you are looking for exists. It is just not always where the directory says. We are here to help families find it, and to keep score on the practices that refuse to be it. Now we know what we are fighting. Together.