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Strengthen the Evidence for Maternal and Child Health Programs

New: MCHbest strategies database for sample ESMs

Evidence Tools
MCHbest. NPM 12: Health Care Transition

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Strategy. Medical Home Integration

Approach. Incorporate transition strategies into medical home systems.

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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):

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

  • Number of medical homes with systems in place to provide transition care.

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

  • Percentage of medical homes with systems in place to provide transition care.

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

  • Number of adolescents in medical homes who receive services necessary to make transitions to adult health care.

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

  • Percentage of adolescents in medical homes who receive services necessary to make transitions to adult health 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.


1AMCHP. November 2009. Models of Care Children and Youth with Special Health Care Needs:Promising Models for Transforming California's System of Care.

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.