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Strengthening the evidence base for maternal and child health programs

New: MCH Best strategies database for sample ESMs

Evidence Tools
MCH Best. NPM 12: Health Care Transition

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happy young man working on a tabletTransition Care Coordination Services

MCH Strategy. Use care coordinators at clinics to help with appointments, scheduling, education, and other health care transition services.

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Overview. Implementing recommended health care transition care coordination practices improved patient or patient caregiver perception of quality of chronic illness care and care coordination especially among the most complex patients..1

Evidence. Moderate Evidence. There is moderate evidence on the scale of effectiveness of care coordination on health care transition. Studies have found improved perception of care and also increased successful transition based on clinic attendance. This strategy appears to be effective in many settings. Access the peer-reviewed evidence through Outcome Evidence for Structured Pediatric to Adult Health Care Transition Interventions: A Systematic Review and Outcomes of pediatric to adult health care transition interventions: An updated systematic review (Got Transition/Center for Health Care Transition Improvement). (Read more about understanding evidence ratings).

Target Audience. Patients, caregivers, state/national, health care providers, health care practices, systems.

Outcome. Clinic attendance, medication adherence, satisfaction with services; receipt of transition education and receipt of age-appropriate transition services; parent knowledge. See the AMCHP/Got Transition NPM 12 Implementation Toolkit: Measurement and Assessment Strategic Approaches for tools to download. 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 11 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. Current agency-based examples drawn from the AMCHP/Got Transition NPM 12 Implementation Toolkit: Care Coordination Strategic Approaches include:

Sample ESMs. Using the strategy “Use care coordinators at clinics to help with appointments, scheduling, education, and other health care transition services,” 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 clinics with care coordination provided for transition within their primary or specialty care provider setting.

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

  • Percentage of clinics with care coordination provided for transition within their primary or specialty care provider setting.
  • Percent of patients/family surveys showing satisfaction with care coordination services.

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

  • Number of parents who indicate increased knowledge about the importance of transition after education by care coordinator.
  • Number of adolescents with a care coordinator who successfully transition to adult care.

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

  • Percentage of parents who indicate increased knowledge about the importance of transition after education by care coordinator.
  • Percentage of adolescents with a care coordinator who successfully transition to adult care.

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.


Reference:

1 Lemke, M., Kappel, R., McCarter, R., D’Angelo, L., & Tuchman, L. K. (2018). Perceptions of health care transition care coordination in patients with chronic illness. Pediatrics, 141(5). https://doi.org/10.1542/peds.2017-3168.

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.