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Strengthen the Evidence for Maternal and Child Health Programs

Evidence Tools
Medical Home: Referrals

Introduction

This toolkit summarizes content from the Medical Home: Referrals 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 care coordination.

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.

Overview: Read a summary of the issue related to Title V

In a pediatric medical home, the primary health care professional helps the child and family access and coordinate care that is important to their overall health and well-being.1,2 Referrals typically involve directing a child and family to specialists or services outside the primary care setting, such as medical sub-specialists, surgical specialists, therapists, early intervention, educational services, and community resources, to meet a child’s health and social needs.1,2 In many cases, referrals from approved providers are needed for health insurance to cover the cost of specialty care.3 A provider’s choice to refer may be affected by the severity and complexity of the child’s health concerns, the family’s desires, health insurance coverage, the availability of qualified specialists in the area, and local or regional variation in how therapies are delivered.4

Referrals is one of the components of the composite medical home measure.5 Referral access is important for addressing unmet health and social needs. Communication and coordination are essential; all care providers need to collaborate to establish shared care plans in partnership with the child and family and develop a clear understanding of each other’s roles to provide comprehensive care.2A strong cross-sector referral infrastructure is needed to improve child health through the integration of clinical and social care.6

Although referral to subspecialty care is an important task within primary care and occurs on average at least once annually for every 3 pediatric patients, the process of connecting children and families with subspecialists can be challenging.7 Families without ready access to pediatric subspecialists are less likely to receive subspecialty care, more likely to receive care from specialists who are not trained in pediatrics, and more likely to report emergency department visits.7  Access to referrals is often increased when a care coordinator, peer navigator, or community health worker is designated to assist children and families with obtaining and accessing needed specialty referrals in addition to helping them access equipment and services that may require referrals.8

Barriers to referrals include barriers faced by families and/or communities, such as difficulty leaving work, obtaining childcare, obtaining transportation, and inadequate health insurance; and barriers related to the health care system, such as workforce shortages, limited appointment availability, geographic location, communication challenges, and lack of access to interpreters.9 Families experiencing many barriers had greater risk of incomplete referral.9 It is critical to reduce barriers to referrals to improve rates of care usage among children who are underserved.9

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

Data Sources: Learn more about the issue and access the data directly

1. Accelerate with EvidenceStart 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.

Chart of Evidence-Linked Strategies and Tools

Evidence-Informed

Evidence-Based

Mixed Evidence

Emerging Evidence

Expert Opinion

Moderate Evidence

Scientifically Rigorous

   

Field-Based Strategies: Find promising programs from AMCHP’s Innovation Hub

Key Findings and Emerging Issues: Read more from the literature

The following are key findings emerging from the literature:

  1. Telehealth can facilitate warm handoffs25 and access to patient navigators.26 Children using telehealth referrals are three times more likely to complete screening; parents report higher satisfaction with overall care.27,28
  2. Electronic referral trackers have proven effective at increasing referrals and ensuring appropriate follow-up care.29,30,31 Providing automated alerts to physicians increases the likelihood of patients receiving a specialty referral.32 Studies show promising results for integration of technology (e.g., mobile apps).33
  3. Combining services to incorporate specialty consultation referrals or care in primary care has proven effective.34 Nurse practitioner subspeciality programs are efficient and cost effective.35 On-site community health workers,36 mental healthcare specialists,37 and embedded psychiatric consultations38 all increase successful referrals.
  4. Care coordinators are effective in connecting families with needed referrals to community-based health programs, 36 social services,26vision care,39 and transportation services.40 Other methods that have proven effective include coordinated discharge instructions.41 Warm handoffs also lead to significant improvement in access to referrals and increase the likelihood that patients will access follow-up care.1,42,37
  5. A cost-effective method of improving access to needed referrals is to provide enhanced screening practices with direct referral pathways. Many models have shown effectiveness: the roadmap model supporting families awaiting consultation after a referral;34 Screen-Refer-Treat, Plan-Do-Study-Act, Early Screening for Autism and Communication Disorders, and Get SET (Screening, Evaluation, and Treatment) Early models, which aim to improve early access to autism spectrum disorder screening, treatment, and referral;29,30,43,44,45 checklists for families receiving the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC);46 early intervention programs;36 pain management programs; 47 screening, brief intervention, and referral to treatment;48 and broader screening during well-child visits.49

Research. Multiple strategies are emerging as potential approaches to advance this NPM, but haven’t been studied with enough rigor to be included in the evidence-based continuum. Additional research is needed to verify outcomes, but initial studies have shown promise of these strategies in MCH settings:

  • Providing training to physicians and caregivers to improve understanding of screening methods and accessing needed referrals.50,51,52
  • Providing school-based options to facilitate care coordination and referral access to mental health and community services.53,54

Research Gaps: Learn where more study is needed

Topical Area Knowledge Gaps. Lack of studies on:

  • Understanding the specific barriers that prevent children from completing referrals to necessary services.
  • Exploring the disparities in access to specialty services for CYSHCN, particularly in underserved geographic areas and populations.
  • Investigating ways to minimize delays in connecting families to necessary services, including improving systems for referral completion and follow-up to ensure timely access to interventions.

Specific Intervention Research Gaps. Lack of studies on:

  • Supporting healthcare providers to effectively implement screening protocols, address knowledge gaps, and increase confidence in identifying at-risk children in need of referrals to specialty care.
  • Providing training to physicians and caregivers to improve understanding of screening methods and accessing needed referrals.
  • Evaluating the effectiveness of collaborative care models that link primary care providers with specialty services to improve the utilization of behavioral health services for children. 
  • Implementing school-based options to facilitate care coordination and referral access to mental health and community services.

Strategy Video: Watch a summary of evidence-based/informed strategies

Watch a short video discussing state-of-the-art, evidence-based/informed strategies that can be used or adapted as ESMs. Experts in the field discuss approaches, the science, and specific ways that Title V agencies can implement and measure these approaches.

2. Think Upstream with Planning ToolsLead 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.

A. 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

B. Align with the Needs of the Population

Consider the following findings related to this performance measure.

The Role of Title V: Get ideas on how to implement strategies

Title V programs can help support a robust and high-functioning referral network by partnering with Medicaid, providers, health plans, and others to:

  • Implement family-centered referral policies.16
  • Designate dedicated and trained staff to make referrals and follow-ups to ensure completion.16
  • Establish and promote registries of community-based providers and services.16
  • Enhance referrals to and integration with other services, such as home visiting, family support, and early intervention, to advance high performing medical homes.24

SDOH and Health Equity Considerations: Identify ways to advance health for all

Social Determinants of Health (SDOH)

SDOH can impact the ability of children and families to obtain referrals and subsequently access health care services.12 This is the result of persistent structural and systemic barriers to health equity including racism, classism, ableism, and the like.13 Efforts to improve socioeconomic conditions, enhance health literacy, expand access to health care resources, and understand cultural diversity can contribute to better access to referrals and receipt of heath care for children who are underserved.14,15

While barriers exist in providing effective community-based referrals for social service needs, such as lack of transportation, being unaware of eligibility, having difficulty navigating application and enrollment processes, and the stigma associated with accessing income-based eligibility services, a strong referral network of appropriate and qualified providers and effective coordination are critical to ensure children and their families receive services to address social needs.16 Communities that offered a large range of public health supports and also had a large number of contributing organizations experienced a nearly 20% reduction in mortality rates across the life span.16

Health Equity

Children from families with limited incomes, of Black race/ethnicity, or uninsured use less specialty care, and those from minority backgrounds report more problems accessing specialty care.9 A reason for low use of specialty care among children who are underserved may be an incomplete referral or not attending an appointment when referred,9 due to implicit bias in health care and systemic barriers to health equity.13 Families experiencing barriers to care also tend to report high levels of social risk and unmet needs, such as housing and food insecurity.17

Strategies to increase equity in referrals include:

  • Patient and family navigation services to assist families in understanding the health care system, schedule appointments, and navigate insurance coverage to support referral completion.18,19
  • Culturally tailored interventions with culturally competent providers to encourage families to seek needed referrals.20
Telemedicine and technology-based solutions to reach children and families in underserved communities and facilitate consultations and referrals without the need for extensive travel.21

Special Considerations: Tease out ways to zoom in on populations of focus

CYSHCN

Families of CYSHCN describe a fragmented health care system with significant unmet health and social needs.22 Medicaid managed care contracting is a common strategy that state Medicaid agencies are using to implement or expand systematic SDOH referral networks and ensure that high need populations, including CYSHCN, receive social services (see examples).16 Medicaid and the Children’s Health Insurance Program (CHIP) are well positioned to facilitate referrals to community-based organizations to address SDOH of CYSHCN.16 Partnerships between Medicaid and Title V are critical for increasing and improving community referrals to support social needs and enhancing cross-agency referrals.23

3. Work Together with Implementation ToolsMove from Planning to Practice

The third step in developing effective, evidence-based/informed programs calls us to work together to ensure that programs are movable within the realities of Title V programs and lead to health equity 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

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:

Partnership. The following organizations focus efforts on improving referrals:


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

Toolkit References: From the Evidence Accelerator

1 American Academy of Pediatrics. (2022 May). What is Medical Home?

2 American Academy of Pediatrics. (2015 November). A medical home where everybody knows your name.

3 Dignity Health. (2015 October). Understanding the referral process.

4 National Academies of Sciences, Engineering, and Medicine. (2023). The Future Pediatric Subspecialty Physician Workforce: Meeting the Needs of Infants, Children, and Adolescents.

5 Lichstein, J. C., Ghandour, R. M., & Mann, M. Y. (2018). Access to the Medical Home Among Children With and Without Special Health Care Needs. Pediatrics, 142(6), e20181795.

6 Hogg‐Graham, R., Edwards, K., L Ely, T., Mochizuki, M., & Varda, D. (2021). Exploring the capacity of community‐based organisations to absorb health system patient referrals for unmet social needs. Health & Social Care in the Community, 29(2), 487-495.

7 Bohnhoff, J. C., Taormina, J. M., Ferrante, L., Wolfson, D., & Ray, K. N. (2019). Unscheduled referrals and unattended appointments after pediatric subspecialty referral. Pediatrics, 144(6).

8 National Academy for State Health Policy. (2020 October). National care coordination standards for children and youth with special health care needs. https://www.nashp.org/wp-content/uploads/2020/10/care-coordination-report-v5.pdf

9 Zuckerman, K. E., Perrin, J. M., Hobrecker, K., & Donelan, K. (2013). Barriers to specialty care and specialty referral completion in the community health center setting. The Journal of pediatrics, 162(2), 409–14.e1.

10 Child and Adolescent Health Measurement Initiative. 2022 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). Retrieved [04/16/2024] from [www.childhealthdata.org]. NSCH 2022: Medical Home Component: Difficulties getting referrals to see any doctors or receive any services, Nationwide (childhealthdata.org)

11 Child and Adolescent Health Measurement Initiative. 2022 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). Retrieved [04/16/2024] from [www.childhealthdata.org]. NSCH 2022: Medical Home Component: Difficulties getting referrals to see any doctors or receive any services, Nationwide, Special health care needs status (childhealthdata.org)

12 Sokol, R., Austin, A., et al. (2019). Screening children for social determinants of health: a systematic review. Pediatrics, 144(4).

13 Houtrow, A., Martin, A. J., Harris, D., Cejas, D., Hutson, R., Mazloomdoost, Y., & Agrawal, R. K. (2022). Health equity for children and youth with special health care needs: a vision for the future. Pediatrics, 149(Supplement 7).

14 Okoniewski, W., Sundaram, M., et al. (2022). Culturally sensitive interventions in pediatric primary care settings: a systematic review. Pediatrics, 149(2).

15 Kibakaya, E. C., & Oyeku, S. O. (2022). Cultural humility: a critical step in achieving health equity. Pediatrics, 149(2).

16 Honeberger, K., Tanga, A.M. (2020 July). Social determinants of health in Medicaid and the role of Medicaid Managed Care contracts. National Academy for State Health Policy. National Resource Center for Patient/Family-Centered Medical Home.

17 Sandhu, S., Lian, T., Smeltz, L., Drake, C., Eisenson, H., & Bettger, J. P. (2022). Patient barriers to accessing referred resources for unmet social needs. The Journal of the American Board of Family Medicine, 35(4), 793-802.

18 AMCHP. (2018 March). Family navigation implementation strategies: Improving systems of care. Issue Brief.

19 Guevara, J. P., Rothman, B., et al. (2016). Patient navigation to facilitate early intervention referral completion among poor urban children. Families, systems & health: The Journal of Collaborative Family Healthcare, 34(3), 281–286.

20 Joo, J. Y., & Liu, M. F. (2021). Culturally tailored interventions for ethnic minorities: A scoping review. Nursing open, 8(5), 2078–2090.

21 Blank, L., Baxter, S., Woods, H. B., Goyder, E., Lee, A., Payne, N., & Rimmer, M. (2014). Referral interventions from primary to specialist care: a systematic review of international evidence. British Journal of General Practice, 64(629), e765-e774.

22 Kuo, D. Z., Rodgers, R. C., Beers, N. S., McLellan, S. E., & Nguyen, T. K. (2022). Access to services for children and youth with special health care needs and their families: concepts and considerations for an integrated systems redesign. Pediatrics, 149(Supplement 7).

23 AMCHP. Collaborations Between State Title V Maternal and Child Health Programs and Medicaid.

24 Johnson K, Willis D, Doyle S. Guide to Leveraging Opportunities Between Title V and Medicaid for Promoting Social-Emotional Development. Center for the Study of Social Policy and Johnson Group Consulting, Inc. 2020.

25 Anand, P., & Desai, N. (2023). Correlation of Warm Handoffs Versus Electronic Referrals and Engagement With Mental Health Services Co-located in a Pediatric Primary Care Clinic. The Journal of adolescent health, 73(2), 325–330.

26 Messmer, E., Brochier, A., et al. (2020). Impact of an On-Site Versus Remote Patient Navigator on Pediatricians' Referrals and Families' Receipt of Resources for Unmet Social Needs. Journal of primary care & community health.

27 Contreras, S., Porras-Javier, L., et al. (2018). Development of a Telehealth-Coordinated Intervention to Improve Access to Community-Based Mental Health. Ethnicity & disease, 28(Suppl 2), 457–466.

28 Coker, T. R., Porras-Javier, L., et al. (2019). A Telehealth-Enhanced Referral Process in Pediatric Primary Care: A Cluster Randomized Trial. Pediatrics, 143(3), e20182738.

29 Conroy, K., Rea, C., et al. (2018). Ensuring Timely Connection to Early Intervention for Young Children With Developmental Delays. Pediatrics, 142(1), e20174017.

30 Schrader, E., Delehanty, A. D., et al. (2020). Integrating a New Online Autism Screening Tool in Primary Care to Lower the Age of Referral. Clinical pediatrics, 59(3), 305–309.

31 Ray, K. N., Drnach, M., et al. (2018). Impact of Implementation of Electronically Transmitted Referrals on Pediatric Subspecialty Visit Attendance. Academic pediatrics, 18(4), 409–417.

32 Wissel, B. D., Greiner, H. M., et al. (2023). Automated, machine learning-based alerts increase epilepsy surgery referrals: A randomized controlled trial. Epilepsia, 64(7), 1791–1799.

33 Alberts, J. L., Modic, M. T., et al. (2019). Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion. Journal of visualized experiments: JoVE, (143), 10.3791/58962.

34 Godwin, D. L., Cervantes, J., et al. (2022). A Road Map for Academic Developmental-Behavioral Pediatric Practices to Increase Access. Journal of developmental and behavioral pediatrics: JDBP, 43(9), 540–544.

35 Jarczyk, K. S., Pieper, P., et al. (2018). An Integrated Nurse Practitioner-Run Subspecialty Referral Program for Incontinent Children. Journal of pediatric health care, 32(2), 184–194.

36 Germán, M., Alonzo, J. K., et al. (2023). Early Childhood Referrals by HealthySteps and Community Health Workers. Clinical pediatrics, 62(4), 321–328.

37 Godoy, L., Hamburger, S., et al. (2023). DC Mental Health Access in Pediatrics: Evaluating a Child Psychiatry Access Program in Washington, DC. Journal of pediatric health care, 37(3), 302–310.

38 Spencer, A. E., Chiang, C., et al. (2019). Utilization of Child Psychiatry Consultation Embedded in Primary Care for an Urban, Latino Population. Journal of health care for the poor and underserved, 30(2), 637–652.

39 McClendon, S., & Zeni, M. B. (2020). Evaluation of Vision Referral Program With School-Aged Children and Their Parents/Guardians. The Journal of school nursing, 36(4), 243–250.

40 Sprecher, E., Conroy, K., et al. (2018). Utilization of Patient Navigators in an Urban Academic Pediatric Primary Care Practice. Clinical pediatrics, 57(10), 1154–1160.

41 Kenyon, C. C., Strane, D., et al. (2020). An Asthma Population Health Improvement Initiative for Children With Frequent Hospitalizations. Pediatrics, 146(5), e20193108.

42 Sanderson, D., Braganza, S., et al. (2021). "Increasing Warm Handoffs: Optimizing Community Based Referrals in Primary Care Using QI Methodology". Journal of primary care & community health.

43 Ibañez, L. V., Stoep, A. V., et al. (2019). Promoting early autism detection and intervention in underserved communities: study protocol for a pragmatic trial using a stepped-wedge design. BMC psychiatry, 19(1), 169.

44 Sheldrick, R. C., Frenette, E., et al. (2019). What Drives Detection and Diagnosis of Autism Spectrum Disorder? Looking Under the Hood of a Multi-stage Screening Process in Early Intervention. Journal of autism and developmental disorders, 49(6), 2304–2319.

45 Smith, C. J., James, S., et al. (2022). Implementing the Get SET Early Model in a Community Setting to Lower the Age of ASD Diagnosis. Journal of developmental and behavioral pediatrics: JDBP, 43(9), 494–502.

46 Farmer, J. E., Falk, L. W., et al. (2022). Developmental Monitoring and Referral for Low-Income Children Served by WIC: Program Development and Implementation Outcomes. Maternal and child health journal, 26(2), 230–241.

47 Kingsley R. A. (2020). A Healthcare Improvement Initiative to Increase Multidisciplinary Pain Management Referrals for Youth with Sickle Cell Disease. Pain management, 21(5), 403–409.

48 Roubil, J. G., Hazeltine, M. D., et al. (2022). Assessing screening, brief intervention, and referral to treatment (SBIRT) compliance and disparities for pediatric inpatients at a tertiary care facility. Journal of pediatric surgery, 57(1), 111–116.

49 Wakai, T., Simasek, M., et al. (2018). Screenings during Well-Child Visits in Primary Care: A Quality Improvement Study. Journal of the American Board of Family Medicine: JABFM, 31(4), 558–569.

50 Chödrön, G., Barger, B., et al. (2021). "Watch Me!" Training Increases Knowledge and Impacts Attitudes Related to Developmental Monitoring and Referral Among Childcare Providers. Maternal and child health journal, 25(6), 980–990.

51 Wissel, B. D., Greiner, H. M., et al. (2023). Automated, machine learning-based alerts increase epilepsy surgery referrals: A randomized controlled trial. Epilepsia, 64(7), 1791–1799.

52 Chödrön, G., Barger, B., et al. (2021). "Watch Me!" Training Increases Knowledge and Impacts Attitudes Related to Developmental Monitoring and Referral Among Childcare Providers. MCH Journal, 25(6), 980–990.

53 Burke, R. E., Hoffman, N. D., et al. (2021). Screening, Monitoring, and Referral to Treatment for Young Adolescents at an Urban School-Based Health Center. The Journal of school health, 91(12), 981–991.

54 McClendon, S., & Zeni, M. B. (2020). Evaluation of Vision Referral Program With School-Aged Children and Their Parents/Guardians. The Journal of school nursing, 36(4), 243–250.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.