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Strengthen the Evidence for Maternal and Child Health Programs

New: MCHbest strategies database for sample ESMs

Evidence Tools
MCHbest. NPM 11: Medical Home

MCHbest Logo young parents holding and looking at their baby

Strategy. Shared Care Coordination with Home Visiting

Approach. Develop early connections to a medical home model through care coordination and collaboration with home visiting.

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Overview. Initial research shows promise between a partnership of primary care clinics and home visiting programs in low-income communities to develop a shared protocol for contacting and interacting with families to encourage participation in both well-child visits and the home visiting program. The primary care clinic and home visiting program personnel can develop a communication protocol based on identified needs for interacting with families.1

Title V Role. Title V agencies can work with the home visiting program to develop an automated data support systems to identify patient need, develop shared plans of care, foster partnerships between primary care practices and community agencies to solve system- and family-level problems, and create a shared care coordination and measurement processes across multiple clinics to increase the percent of the neighborhood population that is reached. For systems-based ideas of how to incorporate care coordination to advance participation in a medical home model, see the National Standards for Children and Youth with Special Health Care Needs: 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. Access the peer-reviewed evidence through the MCH Digital Library (link coming soon). (Read more about understanding evidence ratings).

Target Audience. Provider/Practice and Community-Based Program/Home Visiting Program.

Outcome. Increased primary, preventive, and dental care. 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 no ESMs across all states/jurisdictions that use this strategy directly or intervention components that align with this strategy. However, there are 10 ESMs that measure a shared plan of care approach. 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 “Create a shared care coordination and measurement process between primary care clinics and community-based programs,” 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):

Quadrant 1:
Measuring Quantity of Effort
("What/how much did we do?")

  • Number of care coordinators in designated zip code with a formal relationship with community-based programs.
  • Number of primary care clinics and community-based programs with a protocol for shared communication within a zip code.
  • Number of primary care providers and home visiting providers who participate in regular conference calls to update care coordination and measurement protocol within a community footprint.

Quadrant 2:
Measuring Quality of Effort
("How well did we do it?")

  • Percent of home visitors and primary care providers in the program who participate in regular conference calls to update care coordination and measurement protocol.
  • Percent of primary care providers with a zip code with formalized agreements with community based programs to share information.
  • Percent of primary care providers with a shared care coordination and measurement protocol within a designated community.

Quadrant 3:
Measuring Quantity of Effect
("Is anyone better off?")

  • Number of providers who report change in knowledge and use of shared care coordination and measurement protocol.
  • Number of children referred to the medical home care coordinator from the community-based program.
  • Number of communities implementing a shared care coordination and measurement protocol across.

Quadrant 4:
Measuring Quality of Effect
("How are they better off?")

  • Percentage of children receiving services in a medical home who were referred from a community-based program
  • Percentage of primary care coordinators who report increased competence with communication and data entry with shared measurement database.

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).

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.


1 Brown, C. M., Perkins, J., Blust, A., & Kahn, R. (2015). A neighborhood-based approach to population health in the pediatric medical home. Journal of Community Health, 40(1), 1-11.

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.