MCH Best. NPM 12: Health Care Transition
Strategy. State Policy/System Development
Approach. Partner with organizations to encourage adoption of evidence-driven health care transition (HCT) practices and policies.
Overview. Partnerships with organizations such as family and youth organizations, disabillity groups, state agencies, payers, and health plans, and school systems has shown increased knowledge of and adoption of HCT practices and policies.
There are several methods to accomplish this:
- Method 1: Partner with family and youth organizations and disability groups to increase demand for improved HCT supports.
- Method 2: Partner with sister state agencies, payers, and health plans to encourage adoption of evidence-driven HCT practices and policies.
- Title V Examples: Florida’s Children’s Rehabilitation Service managed care requirements for HCT performance improvement project. DC (under contract to The National Alliance to Advance Adolescent Health) produced a policy options paper for its Medicaid agency.
- Method 3: Partner with school systems to encourage adoption of evidence-driven HCT practices and policies.
- Title V Examples: DC (with The National Alliance) worked with several SBHCs; customized tools from the Six Core Elements (welcome and care policy, transition readiness assessment, and finding an adult doctor) and demonstrated improvement in level of HCT implementation as part of adolescent well visits. Michigan replicated this HCT approach and is expanding to other SBHCs in the state.
Evidence. Expert opinion. Strategies with this rating are recommended by credible, impartial experts and are consistent with accepted theoretical frameworks. However, the strategies have limited research documenting effects; further research, often with stronger designs, is needed to confirm effects. This strategy was drawn from NPM 12: Health Care Transition, NPM Webinar Series (2020).
Target Audience. Health care practices/clinics/systems, care coordination programs, managed care organizations, public health programs.
Outcome. Can be measured in several ways -- self-care knowledge/skills, adherence to care, disease-specific measures, clinician experience with transition process, time between last pediatric and initial adult visit, preventive/ambulatory care visits in adult settings, emergency room visits, hospital use, and costs of care.
Examples from the Field. Access descriptions of current ESMs that use this strategy directly or intervention components that align with this strategy. You can use these ESMs to see how other Title V agencies are addressing the NPM.
Sample ESMs. Using the approach “Partner with organizations to encourage adoption of evidence-driven health care transition (HCT) practices and policies,” 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).
Note and Reference:
1 White PH, Cooley WC, Transitions Clinical Report Authoring Group, American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians. Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home. Pediatrics. 2018;142(5):e20182587
Note: Got Transition is now offering the updated Six Core Elements of Health Care Transition™ 3.0, which define the basic components of HCT support. The Six Core Elements 3.0 are intended for use by pediatric, family medicine, med-peds, and internal medicine practices.To help practices transform their HCT processes, Got Transition has also developed new practical step-by-step Implementation Guides dedicated to each core element. Got Transition offers background information on how to use the Implementation Guides, as well as a Quality Improvement Primer for those unfamiliar with the QI process. Guides and information are available at www.GotTransition.org/Implementation.