Evidence Tools
Medical Home: Care Coordination
Introduction
This toolkit summarizes content from the Medical Home: Care Coordination Evidence Accelerator and the MCHbest database. The peer-reviewed literature supporting this work can be found in the Established Evidence database. Use the resources below as you develop effective evidence-based/informed programs and measures.
This NPM is one of five measures in support of the Medical Home Overall Measure (a Universal Measure); access each of the individual Accelerators here: the percent of children with and without special health care needs, ages 0 through 17, who have a personal doctor or nurse; have a usual source of sick care; are provided with family-centered care; and receive needed referrals.
From the MCH Block Grant Guidance. The American Academy of Pediatrics (AAP) specifies seven qualities essential to medical home care, which include accessible, family-centered, continuous, comprehensive, coordinated, compassionate and culturally effective. Providing comprehensive and coordinated care to children in a medical home is the standard of pediatric practice. Research indicates that children with a stable and continuous source of health care are more likely to receive appropriate preventive care, are less likely to be hospitalized for preventable conditions, and are more likely to be diagnosed early for chronic or disabling conditions.
Goal. To increase the percent of children with and without special health care needs who have a medical home.
Note. Access other related measures in this Population Domain through the Toolkits page.
Detail Sheet: Start with the MCH Block Grant Guidance
DEFINITION
Numerators:
Number of children with and without special health care needs, ages 0 through 17, who are reported by a parent to meet the criteria for having a medical home (personal doctor or nurse, usual source for care, family-centered care, referrals if needed, and care coordination if needed)
Number of children with and without special health care needs, ages 0 through 17, who have a personal doctor or nurse
Number of children with and without special health care needs, ages 0 through 17, who are reported by a parent to have a place they usually go when the child is sick or needs advice about their health (excluding the hospital emergency room)
Number of children with and without special health care needs, ages 0 through 17, who are reported by a parent that the child’s doctor or other health care provider always/usually 1) spent enough time with the child, 2) listened carefully to the child, 3) showed sensitivity to family values, 4) provided the specific information needed concerning the child, and 5) helped the family feel like a partner in the child’s care
Number of children with and without special health care needs, ages 0 through 17, who are reported by a parent to have no problem getting needed referrals
Number of children with and without special health care needs, ages 0 through 17, who are reported by a parent to have received all needed help with care coordination
Denominators:
Number of children with and without special health care needs, ages 0 through 17
Number of children with and without special health care needs, ages 0 through 17
Number of children with and without special health care needs, ages 0 through 17
Number of children with and without special health care needs, ages 0 through 17, who are reported by a parent to have had a visit with a health care professional in the past 12 months
Number of children with and without special health care needs, ages 0 through 17, who are reported by a parent to have needed a referral to see any doctors or receive any services in the past 12 months
Number of children with and without special health care needs, ages 0 through 17, who are reported by a parent to have needed care coordination past 12 months
Units: 100
Text: Percent
HEALTHY PEOPLE 2030 OBJECTIVE
Related to Maternal, Infant, and Child Health (MICH) Objective 19: Increase the proportion of children and adolescents who receive care in a medical home. (Baseline: 48.6% in 2016-17, Target: 53.6%)
DATA SOURCES
National Survey of Children's Health (NSCH)
MCH POPULATION DOMAIN
Children with Special Health Care Needs, All Children (CSHCN and non-CSHCN), or All Adolescents (CSHCN and non-CSHCN)
MEASURE DOMAIN
Clinical Health Systems
1. Accelerate with Evidence—Start with the Science
The first step to accelerate effective, evidence-based/informed programs is ensuring that the strategies we implement are meaningful and have high potential to affect desired change. Read more about using evidence-based/informed programs and then use this section to find strategies that you can adopt or adapt for your needs.
Evidence-based/Informed Strategies: MCHbest Database
The following strategies have emerged from studies in the scientific literature as being effective in advancing the measure. Use the links below to read more about each strategy or access the MCHbest database to find additional strategies.
| Evidence-Informed |
Evidence-Based |
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Mixed Evidence |
Emerging Evidence |
Expert Opinion |
Moderate Evidence |
Scientifically Rigorous |
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Field-Based Strategies: Find promising programs from AMCHP’s Innovation Hub
Cutting Edge:
- Cultural Broker (VA; 2022)
- First Responder Care Coordination (National; 2024)
- Increased Access to Telehealth Services (UT; 2021)
Emerging:
- Care Coordination Transition Program (FL;2011)
- Care Coordination-Based Program (VA; 2018)
- Directory of Relevant Service Providers and Resources (Multiple States; 2023)
- Family Navigator Network (IA; 2020)
- Increase Family Knowledge and Hands-On Practicum Experience (TN; 2022)
- Statewide Registry of Emergency Medical Information (OR; 2023)
- Systems Assessment on Care Coordination (MN; 2016)
Promising:
- Care Coordination Program (OR; 2009)
- Home-Visiting Services (PA; 2021)
Best:
- Bilingual Community Health Workers (SC; 2019)
- Community-Based Care Coordination Network (National; 2023)
- Promote Child, Family, and Community Well-Being (National; 2021)
2. Think Upstream with Planning Tools—Lead with the Need
The second step in developing effective, evidence-based/informed programs challenges us to plan upstream to ensure that our work addresses issues early and is measurable in “turning the curve” on big issues that face MCH populations. Read more about moving from root causes to responsive programs and then use this section to align your work with the data and needs of your populations.
Move from Need to Strategy
Use Root-Cause Analysis (RCA) and Results-Based Accountability (RBA) tools to build upon the science to determine how to address needs.
Planning Tools: Use these tools to move from data to action
3. Work Together with Implementation Tools—Move from Planning to Practice
The third step in developing effective, evidence-based/informed programs calls us to work together to ensure that programs are implementable and moveable within the realities of Title V programs and lead to improved health outcomes for all people. Read more about implementation tools designed for MCH population change and then use this section to develop responsive strategies to bring about change that is responsive to the needs of your populations.
Additional MCH Evidence Center Resources: Access supplemental materials from the literature
- Find field-based resources focused on increasing access to care coordination relevant to Title V programs in the MCH Digital Library.
- Search the Established Evidence database for peer-reviewed research articles related to strategies for increasing access to care coordination.
- Request Technical Assistance from the MCH Evidence Center
- MCH Evidence Center Frameworks and Toolkits:
Implementation Resources: Use these field-generated resources to affect change
Practice. The following tools can be used to translate evidence to action to advance this NPM:
- National Care Coordination Standards for CYSHCN (NASHP). The standards outline core, system-level components of high-quality care coordination for CYSHCN.
- Interprofessional Education in Care Coordination: An Interprofessional Resource to Effectively Engage Patients and Families in Achieving Optimal Child Health Outcomes, 2nd Ed. (Boston Children’s Hospital). This curriculum supports family-centered care coordination in pediatric medical homes.
Partnership. The following organizations focus efforts on advancing Care Coordination:
- AAP National Resource Center Medical Home Care Coordination Resources. Collection of tools and resources for state agencies (Medicaid, Title V) and others interested in care coordination.
- National Center for Care Coordination Technical Assistance. Provides technical assistance focused on pediatric care coordination capacity building and measurement.
References
Introductory References: From the MCH Block Grant Guidance
1 American Academy of Pediatrics. National Resource Center for Patient/Family-Centered Medical Home. (n.d.) https://medicalhomeinfo.aap.org