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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Medical Home: Care Coordination.

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Strategy. A Shared Plan of Care

Approach. Use a shared plan of care for children with special healthcare needs to ensure needed referrals

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Overview. A care coordination model using a family-centered, goal-oriented Shared Plans of Care. (SPoC) is a feasible and effective approach with a cohort of children with complex neurodevelopmental disorders and is associated with improved family outcomes.[1] Using SPoC is associated with a statistically significant decrease in the number of primary care visits for children with special healthcare needs with mental and behavioral health conditions.[2] Other improvements in outcome measures, include care coordination access, SPoC use, goals achieved, needs met, family empowerment, and reduced worry.[1]

Evidence. Emerging Evidence. Strategies based on emerging evidence show promise but have not undergone extensive testing. While these approaches demonstrate potential, their effectiveness remains unconfirmed. Prioritize rigorous monitoring to ensure they achieve desired outcomes for all MCH populations.

Access the peer-reviewed evidence through the MCH Digital Library or related evidence source.

Potential Data Sources. Data to support this strategy can be accessed through:

  • Pre- and post-program surveys on health knowledge
  • Parent/caregiver health literacy assessments
  • Post-intervention satisfaction surveys

Outcome Components. This strategy has shown to have impact on the following outcomes (Read more about these categories):

  • Quality of Care. This strategy promotes the degree to which healthcare services meet established standards aimed at achieving optimal health outcomes.
  • Patient Experience of Care. This study improves individuals' perceptions, feelings, and satisfaction with the healthcare services they receive.
  • Utilization. This strategy improves the extent to which individuals and communities use available healthcare services.

Detailed Outcomes. For specific outcomes related to each study supporting this strategy, access the peer-reviewed evidence and read the Intervention Results for each study.

Intervention Type. Case Management (Read more about intervention types and levels as defined by the Public Health Intervention Wheel).

Intervention Level. Individual/Family-Focused

Examples from the Field. There are currently no ESMs that use this strategy. Search similar intervention components in the ESM database.

Sample ESMs. Here are sample ESMs to use as models for your own measures using the RBA framework (see The Role of Title V in Adapting Strategies).

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

  • Number of providers adopting shared plans of care for children with special healthcare needs. (Measures uptake of shared care planning approach)
  • Number of children with special needs having an up-to-date shared plan of care. (Assesses reach of shared care planning)

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

  • Percent of shared plans developed collaboratively with families and providers. (Measures family-centered care planning process)
  • Percent of shared plans including comprehensive and responsive assessments. (Assesses holistic approach to care planning)

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

  • Number of families reporting increased partnership in care through shared plans. (Shows family engagement impact)
  • Percent of families reporting high satisfaction and goal achievement through shared plans. (Measures family experience outcomes)
  • Number of healthcare systems integrating shared plans into quality improvement efforts. (Measures systems change impact)
  • Number of communities achieving improvements in care coordination for children with special needs through shared planning. (Assesses population health impact)

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

  • Percent of shared care planning process actively engaging families as equal partners. (Measures authentic family partnership in planning)
  • Percent of shared plans incorporating family-determined goals and measures of success. (Shows family agency in care planning)
  • Percent reduction in gaps in care coordination outcomes within groups of children with special needs. (Measures impact on advancing health outcomes)
  • Percent of families reporting shared plans affirm their identities and experiences. (Assesses responsiveness in care planning)

Note. When looking at your ESMs, SPMs, or other strategies:

  1. Move from measuring quantity to quality.
  2. Move from measuring effort to effect.
  3. Quadrant 1 strategies should be used sparingly, when no other data exists.
  4. The most effective measurement combines strategies in all levels, with most in Quadrants 2 and 4.

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.

References

[1] McAllister, J. W., Keehn, R. M., Rodgers, R., Mpofu, P., Monahan, P. O., & Lock, T. M. (2018). Effects of a Care Coordination Intervention with Children with Neurodevelopmental Disabilities and Their Families. Journal of Developmental and Behavioral Pediatrics, 39(6), 471–480.

[2] Mann, E., Pyevich, M., Eyck, P. T., & Scholz, T. (2020). Impact of Shared Plans of Care on Healthcare Utilization by Children with Special Healthcare Needs and Mental Health Diagnoses. Maternal and Child Health Journal, 25(4), 584–589. https://doi.org/10.1007/s10995-020-03101-3

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.