Skip Navigation

Strengthen the Evidence for Maternal and Child Health Programs

New: MCHbest strategies database for sample ESMs

Evidence Tools
NPM 11

young parents holding and looking at their babyMedical Home


The Title V Maternal and Child Health Services Block Grant to States Program guidance defines the significance of this goal as follows:

The American Academy of Pediatrics (AAP) specifies seven qualities essential to medical home care: accessible, family-centered, continuous, comprehensive, coordinated, compassionate and culturally effective. Ideally, medical home care is delivered within the context of a trusting and collaborative relationship between the child's family and a competent health professional familiar with the child and family and the child's health history.

Providing comprehensive 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 and immunizations, are less likely to be hospitalized for preventable conditions, and are more likely to be diagnosed early for chronic or disabling conditions. The Maternal and Child Health Bureau uses the AAP definition of medical home. (See also the expanded defintion and infographic).

NPM 11 Tools

MCHbest LogoNEW! The MCH Evidence Center is pleased to share Phase 1 of the MCHbest database: the Bank of Evidence-linked Strategies and Tools.

The database aggregates sample evidence-based/informed strategies that can be used as-is or adapted to develop Evidence-based or informed Strategy Measures (ESMs) for each of the MCH National Performance Measures (NPMs). Use the database along with the ESM Development Guide to work through the entire ESM process.

NEW! Watch a short video (below) 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.

Strategy Video

Presented by Jamie Jones, National Resource Center for Patient/Family-Centered Medical Home.


Introductory Resources

  • Evidence Brief (National Center for Education in MCH (NCEMCH) at Georgetown University).
  • Environmental Scan (Women's and Children's Health Policy Center (WCHPC) at Johns Hopkins University). This environmental scan identifies compilations of strategies to advance NPM 11. Read more about environmental scans.
  • Medical Home Timeline. Since the 1960’s, the medical home concept has evolved from initially being a central repository of medical records for children and youth with special health care needs (CYSHCN) to the standard of care for all children and youth, particularly those with special health care needs.

Summary of the Evidence

  • The peer-reviewed evidence identified partnerships and care coordination as critical mechanisms to improve access to care within the medical home model.
  • Use of community collaborators, such as school-based health centers (SBHCs) and outreach via community care coordinators, resulted in more children receiving care within the medical home model. More specifically, collaborations with SBHCs, home visiting programs, or use of enhanced care coordination in underserved, urban neighborhoods or with children in foster care led to positive outcomes. These impacts include increased contact with the medical home model for well-child visits, access to specialty care, better adherence with disease management, and dental care.
  • A shift in state policy was also found to increase access to a medical home for children receiving Medicaid. Moving from a traditional fee-for-service model of health care financing and delivery to a primary care case management model by a Medicaid program resulted in more targeted identification and support for children and their families to enter into a medical home model of care.

Evidence Analysis Report

Promising Practices

National Resource Center for Patient/Family-Centered Medical Home Promising Practices: Access promising practices that have been selected by an expert workgroup as innovative and promising in pediatric medical home implementation.

Innovation Station: You can access strategies from AMCHP’s Innovation Station that have shown promise in advancing your NPM below. While these strategies may not completely align with your current activities, they can be used to help guide further development and measurement of your ESM.

Practice Name Primary Interest State  Level of Evidence
Boys' Health Advocacy Program Child Health SD Promising
e-access Telemedicine Program CYSHCN NY Best
CMS Kids: Medical Foster Care CYSHCN FL Emerging
Pediatric Practice Enhancement CYSHCN RI Promising
Universal Application System CYSHCN UT Emerging
Oregon Care Coordination Program CYSHCN OR Promising
Partners in Care: Together for Kids CYSHCN FL Emerging
CMS-CSHCN Youth Transitions CYSHCN FL Emerging
Children’s Hospital Transition Adolescent Health TX Best
Transition Interagency Group Envisioning Realization of Self CYSHCN CO Emerging
Pathways Community HUB Access to Health Care OH Promising
MN Care Coordination Systems Assessment and Action Planning CYSHCN MN Emerging
Medical Preparedness Pediatrics CYSHCN AK Emerging
First 5 California Kit for New Parents Family Involvement CA Promising
Family Voices of California Project Leadership CYSHCN CA Promising
Community Systems Building Grants for CYSHCN CYSHCN NC Emerging
Partners in Pregnancy Infant Health VA Promising
Care Connection for Children Service Integration VA Emerging

Sample ESMs

Domain and National Performance Measure: Percent of children with/without special healthcare needs having a medical home

Current ESMs: See this list of ESMs currently being implemented by other states/jurisdictions. These ESMs could serve as models for programs in your agency. Please contact us if you would like to discuss how we can work with you to tap these measures for use in your state. This list is drawn from the MCH Digital Library.

Model ESMs: These examples can also serve as models for programs in your state/jurisdiction.

Strategy [Source] Evidence-based/-informed Strategy Measure (ESM)
Support practices with technical assistance to develop and implement family engagement policies [3] # of providers and facilities receiving technical assistance about family engagement
Incentivize practices for participating in QI activities that actively engage patients [3] Policies and programs established to incentivize practices for actively engaging patients;# of practices participating in medical home learning collaborativess
With input from family representatives, create a practice-wide, comprehensive plan of care template that can be used across systems of care for CYSHCN [4] #/% of practices that use a comprehensive plan of care template
Conduct outreach to families about availability and benefits of the medical home [3] % of communities that conducted outreach about the availability and benefits of the medical home

[3] Women’s and Children’s Health Policy Center, Johns Hopkins Bloomberg School of Public Health. Environmental Scans.
[4] Association of Maternal and Child Health Programs & Johns Hopkins Bloomberg School of Public Health. Taking Action with Evidence: Implementation Roadmap Webinars.

Source: Sample Strategies and Evidence-based/informed Strategy Measures (ESMs) (WCHPC). A list of sample strategies and ESMs for each of the 15 NPMs. Sources are provided at the end of the document. 


Additional Learning

Materials from the National Resource Center for Patient/Family Centered Medical Home

  • National Resource Center for Patient/Family-Centered Medical Home. An MCHB-funded technical assistance resource center, this project supports NPM 11 topic areas. The site includes a portal of promising practices in pediatric medial home implementation.
    • Medical Home Resources for State Title V Programs to Achieve National Performance Measure 11
    • Medical Home Initiatives and Resources by State. This portal allows you to search by state for local medical home initiatives and other resources pertinent to your community. You can also access a portal of local Healthy Tomorrow Partnership for Children programs from this page.
    • The Pediatric Care Coordination Curriculum (PCCC): An Interprofessional Resource to Effectively Engage Patients and Families in Achieving Optimal Child Health Outcomes, 2nd Edition. This curricula includes a collection of tools and resources for all individuals, including pediatric clinicians, state agencies (Medicaid, Title V), family advocates, family/professional partnership groups, and other pediatric medical home stakeholders interested in care coordination.
    • AAP Medical Home Resources. This page includes AAP advocacy and policy information, and resources related to general medical home practices, practice transformation and implementation, financing and payment, youth and family engagement, subspecialties, transition to adult care, and certification programs.
    • Medicaid and Children’s Health Insurance Program (CHIP) Profiles.The National Academy for State Health Policy (NASHP) and the former National Center for Medical Home Implementation (National Center) collaborated to develop state profiles that focus on exchanging information to improve medical home access for children and youth in medically underserved populations. States with Medicaid and Children's Health Insurance Program (CHIP) demonstration projects and initiatives, that are proactively advancing the medical home in pediatric populations, are profiled.
    • States At-a-Glance Table. Created by the former National Center for Medical Home Implementation in partnership with the National Academy for State Health Policy this state "at-a-glance" table provides an overview of pediatric medical home initiatives occurring through Medicaid and the Children's Health Insurance Program (CHIP). By learning about ongoing pediatric medical home initiatives in your state, pediatric clinicians, practices, state Title V agencies, American Academy of Pediatrics state chapters, and others can gain insights on how to integrate their work and coordinate efforts across multiple systems.
    • Archived Webinars. Created by the National Resource Center for Patient/Family-Centered Medical Home and former National Center for Medical Home Implementation, these archived webinars can provide Title V programs with practical information, tools, and resources needed to implement or support implementation of the pediatric medical home model.

Additional Resources

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.