MCHbest. NPM 12: Health Care Transition
Strategy. Medical Home Integration
Approach. Incorporate transition strategies into medical home systems.
Overview. Research has shown that medical home models seem to increase issue awareness and improve relationships in a system. Studies in a number of states indicate that medical home strategies "deserve careful consideration by leaders interested in transforming the system of care for CYSHCN."1 Integrating health care transition into the medical home appears to trend positive in ensuring transition planning occurs at appropriate times.
Evidence. Emerging Evidence. There is emerging, recent evidence on the effectiveness of medical home implementation on transition. This strategy has been tested more than once and results trend positive overall. However, more research is needed for conclusive results. 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. Health care practices.
Outcome. Systems with the infrastructure necessary to improve transition services. 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 17 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 “Incorporate transition strategies into medical home systems,” 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).
1AMCHP. November 2009. Models of Care Children and Youth with Special Health Care Needs:Promising Models for Transforming California's System of Care.