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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. Shared Care Coordination with Home Visiting

Approach. Develop early connections to a medical home model through care coordination and collaboration with home visiting

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Overview. Initial research shows promise between a partnership of primary care clinics and home visiting programs in low-income communities to develop a shared protocol for contacting and interacting with families to encourage participation in both well-child visits and the home visiting program. The primary care clinic and home visiting program personnel developed a communication protocol based on identified needs for interacting with families. Neighborhood-based newborn registries, proactive nursing outreach, and collaboration with a home visiting agency aligned multiple clinics in a low-income neighborhood to improve access to health-promoting services within the pediatric medical home.[1]

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:

  • Satisfaction data from care coordinators
  • Family partnership and satisfaction data
  • Key child health and well-being indicators

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. Collaboration (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 communication protocols and care coordination agreements developed between primary care clinics and home visiting programs to facilitate seamless, bi-directional information sharing and referrals. (Assesses the infrastructure and process put in place to support effective collaboration)
  • Number of joint training sessions and learning collaboratives conducted for primary care and home visiting staff to build skills in family engagement, care coordination, and cross-system collaboration. (Measures the capacity building efforts to support partnership success)

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

  • Percent of primary care clinics and home visiting programs in the tailored communities that have formally established partnerships and implemented shared protocols for family outreach and interaction. (Measures the saturation and spread of the partnership approach)
  • Percent of families served by the primary care-home visiting partnership who have a shared care plan that is regularly updated and available to both healthcare and home visiting providers. (Measures the family-centeredness and coordination of care planning process)

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

  • Number of community outreach and engagement events conducted jointly by primary care clinics and home visiting programs to build awareness, trust, and enrollment among various populations. (Measures the efforts to increase access and reduce challenges to care)
  • Number of quality improvement initiatives and data-driven interventions implemented collaboratively by primary care clinics and home visiting programs to address gaps in service utilization. (Measures the use of continuous improvement strategies to optimize partnership impact)
  • Number of preventable child health problems, developmental delays, and adverse childhood experiences avoided for mitigated through the early identification and intervention facilitated by the primary care-home visiting partnership. (Measures the impact of the partnership on improving child health outcomes and reducing risk factors)
  • Number of successful transitions from home visiting to other early childhood programs and services, such as early intervention, Head Start, for preschool, supported by the care coordination and referral process of the partnership. (Measures the long-term impact of the partnership on promoting continuity and alignment across the early childhood system)

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

  • Percent of partnership agreements, communication protocols, and care coordination process that are designed and implemented with input and feedback from families and community community partners. (Measures the level of family and community engagement in shaping the partnership approach)
  • Percent of Title V funding and resources allocated to support primary care-home visiting partnerships in communities with the lowest access to quality healthcare and home visiting services. (Measures the tailored investment and allocation of resources)
  • Percent reduction in gaps for key child health and well-being indicators (e.g., immunization rates, developmental screening, maternal depression) between families served by primary care-home visiting partnerships and those served by traditional, siloed approaches. (Measures the impact of the partnership on advancing health and closing outcome gaps)
  • Percent of families served by the partnership who experience increased access to stable housing, food security, and economic stability, as a result of the comprehensive, coordinated support received. (Measures the impact of the partnership on addressing upstream factors influencing child and family well-being)

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 Brown, C. M., Perkins, J., Blust, A., & Kahn, R. (2015). A neighborhood-based approach to population health in the pediatric medical home. Journal of Community Health, 40(1), 1-11.

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.