MCHbest. NPM 11: Medical Home
Strategy. Provider-School Partnerships
Approach. Develop partnerships between primary care providers (PCPs) and school-based health centers (SBHC) to create an expanded medical home model based on care coordination and increase access of care.
Overview. Use of community collaborators, such as 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. Research shows that when PCPs and local SBHCs partnered in an expanded medical home model, significantly more patients were shared between the sites and more patients benefited from access to care within the expansion of their medical home. Further, patients in the expanded medical home had a higher likelihood of receiving quality services than patients seen only in a PCP’s office. The SBHCs in the study provided comprehensive physical health services, mental health counseling, and nutrition services (as well as helping families meet tangible needs such as housing and food). The SBHC was staffed by a full-time nurse practitioner, full-time social worker, half-time registered dietician, and a primary care physician (PCP) (1 half day/week).1
The Role of Title V: Title V could play an instrumental role in strengthening partnerships or increasing collaborations between practices and school systems in the state/jurisdiction. This strategy could also be tied to adolescent health and increasing outreach to that population as well.
You may want to access Building Student and Family-Centered Care Coordination Through Ongoing Delivery System Design: How School Nurses Can Implement Care Coordination that presents a comprehensive, system-level model of care coordination for school nurse leadership and practice. In addition, view strategies outlined in the AAP webinar Care Coordination for Kids- School Nurses Linking with the Medical Home.
Evidence. Emerging Evidence. The study supporting this intervention provides data indicating that the intervention may be effective. However, the study includes limited research documenting effects and requires further research to confirm effects. More research is needed for conclusive results. Access the peer-reviewed evidence through the MCH Digital Library (link coming soon). (Read more about understanding evidence ratings).
Target Audience. Provider/Practice and School System.
Outcome. Increased well-visits and better medical condition management. For detailed outcomes related to each study supporting this strategy, click on the peer-reviewed evidence link above and read the "Intervention Results" for each study.
Examples from the Field. There are currently 2 ESMs across all states/jurisdictions that use this strategy directly or intervention components that align with this strategy. Access descriptions of these ESMs through the MCH Digital Library. You can use these ESMs to see how other Title V agencies are addressing the NPM.
Sample ESMs. Using the approach “Develop partnerships between primary care providers (PCPs) and school-based health centers (SBHC) to create an expanded medical home model based on care coordination,” here are sample ESMs you can use as a model for your own measures using the Results-Based Accountability framework (for suggestions on how to develop programs to support this strategy, see The Role of Title V in Adapting Strategies):
Note. ESMs become stronger as they move from measuring quantity to measuring quality (moving from Quadrants 1 and 3, respectively, to Quadrants 2 and 4) and from measuring effort to measuring effect (moving from Quadrants 1 and 2, respectively, to Quadrants 3 and 4).
1 Riley, M., Laurie, A. R., Plegue, M. A., & Richardson, C. R. (2016). The adolescent “expanded medical home”: School-based health centers partner with a primary clinic to improve population health and mitigate social determinants of health. Journal of the American Board of Family Medicine, 29(3), 339-347.