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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. State Policy/System Development

Approach. Partner with organizations to encourage adoption of evidence-driven health care transition (HCT) practices and policies.

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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:

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):

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

  • Number of organizations partnered with who are promoting HCT practices and policies.

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

  • Percentage of programs reached out to who are actively partnering to promote HCT practices and policies.

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

  • Number of partnering organizations who report that they have increased HCT services among their constituents.

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

  • Percent of partnering organizations who report that they have increased HCT services among their constituents.

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.

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

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.