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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Medical Home: Overall.

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Strategy. Provider Alliance and Mid-Level Providers

Approach. Use a provider alliance and mid-level providers to create a “one-stop” medical home model to provide community outreach and coordination of services

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Overview. Initial research has shown promise in use of a provider alliance (wherein primary care and subspecialty organizations were operationally linked) for a patient-centered medical home for the delivery of a coordinated continuum of health services. The alliance created a “one-stop” medical home which enrolled children and families in health programs for which they qualified, attached families to medical homes, provided primary care to children, referred families to specialty services as needed, provided clinic-based health education to families, and offered case management support to empower families to navigate the healthcare system.[1] It was also noted that in a patient-centered medical home patients were more likely to receive pediatric counseling on car safety devices, healthy eating habits, exercising, wearing bicycle helmets, not smoking in the home for adults, and so on, which impacts children’s overall health and well-being.[2]

Evidence. Emerging Evidence. Strategies with this rating typically trend positive and have good potential to work...

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:

  • Data on partnership formation and engagement
  • Data on service integration and colocation
  • Evaluation data on community outreach activities

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

  • Access to/Receipt of Care. This strategy increases the ability for individuals to obtain healthcare services when needed, including preventive, diagnostic, and treatment services.
  • Community Health Factors.
  • Patient Experience of Care. This study improves individuals' perceptions, feelings, and satisfaction with the healthcare services they receive.

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

Intervention Level. Community-Focused

Examples from the Field. Access descriptions of ESMs that use this strategy or aligned components.

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 mid-level providers (e.g., nurse practitioners, physician assistants) recruited and trained to provide comprehensive care and care coordination within the medical home model. (Measures the capacity building efforts to expand the healthcare workforce)
  • Number of community outreach events and activities conducted by the provider alliance and mid-level providers to engage and enroll children and families in the medical home. (Measures the efforts to increase access and utilization of the medical home model)

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

  • Percent of provider alliances that have established formal agreements, shared protocols, and interoperable data systems to facilitate seamless care coordination and communication. (Measures the quality and strength of provider collaboration and integration)
  • Percent of mid-level providers who have received specialized training and demonstrate competency in providing patient-centered and evidence-based care within the medical home model. (Measures the effectiveness of workforce development efforts)

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

  • Number of partnerships and collaborations established between the provider alliance, community organizations, schools, and social service agencies to provide wrap-around supports for families. (Measures the level of multi-sector engagement and coordination)
  • Number of policies, payment models, and systems changes educated on and implemented by Title V agencies and partners to support the sustainability and spread of "one-stop" medical home models. (Measures the broader systems-level impact and enablers for model success)
  • Number of children and families from communities that have additional needs in the primary care system who are successfully engaged and served through the "one-stop" medical home model. (Measures the impact on reducing health gaps in access)
  • Number of best practices, lessons learned, and successful medical home models disseminated by Title V agencies and partners to promote the replication and scaling of "one-stop" approaches across communities and populations. (Measures the potential for spread and sustainability of the model)

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

  • Percent of provider alliance agreements, care protocols, and quality improvement efforts that explicitly address trauma-informed care principles and root causes of health outcomes. (Measures the integration of responsiveness into the medical home infrastructure and process)
  • Percent of Title V funding and resources allocated to support "one-stop" medical home models in communities with the highest needs and lowest access to comprehensive, coordinated care. (Measures the tailored investment and allocation of resources to promote utilization)
  • Percent reduction in differences in key child health indicators (e.g., immunization rates, developmental screening, oral health assessment) between children served by the "one-stop" medical home model and those served by traditional care approaches. (Measures the impact on advancing health outcomes and closing health gaps)
  • Percent of overall healthcare costs and utilization for children in the community that shift from high-cost, reactive care to preventive, proactive, and coordinated care as a result of the "one-stop" medical home model. (Measures the long-term financial and system-level impact on population health and value-based care)

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 Tataw, D. B., Bazargan-Hejazi, S., & James, F. (2011). Health services utilization, satisfaction, and attachment to a regular source of care among participants in an urban health provider alliance. Journal of Health and Human Services Administration, 34(1), 109-141.

2 Hill, S. C., & Zuvekas, S. H. (2021). Patient-Centered Medical Homes and Pediatric Preventive Counseling. Academic Pediatrics, 21(3), 488-496.

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.