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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Medical Home: Referrals.

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Strategy. Community-Based Partnerships

Approach. Facilitate community-based care centers in connecting patients with needed services in partner organizations in order to provide more efficient and timely services to communities in need

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Overview. Community-based partnerships improve access to non-medical influences on health resources for families with young children living in low-income, under resourced urban settings. A telehealth-coordinated intervention, developed through a community-partnered approach, can address challenges to accessing community-based mental healthcare through video introductions, live videoconferences, and collaboration between primary care providers and mental health centers.[1] Findings show the integration of community health workers (CHWs) into the Healthy Steps. (HS) care team significantly improves the success rate of referrals for non-medical influences on health (SDOH) concerns among families, with the HS + CHW group achieving a 100% success rate for food services referrals and an 89% success rate for childcare services referrals.[2]

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:

  • Partner engagement and collaboration metrics
  • Patient/family satisfaction surveys
  • Community resource engagement data

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

  • Utilization. This strategy improves the extent to which individuals and communities use available healthcare services.
  • Access to/Receipt of Care. This strategy increases the ability for individuals to obtain healthcare services when needed, including preventive, diagnostic, and treatment services.
  • Health Care Access for All MCH Populations.

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. 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 community-based care centers engaged in partnerships with Title V to connect patients with needed services. (Measures participation in partnership efforts)
  • Number of partner organizations collaborating with community-based care centers to provide coordinated services. (Assesses breadth of partnerships)

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

  • Percent of community-based partnerships with established protocols for coordinating referrals and follow-up. (Measures formalization of partnership process)
  • Percent of care centers and partners engaging in regular joint care planning activities. (Assesses depth of collaboration)

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

  • Number of policies established to support community-based care partnerships. (Assesses enabling factors for partnerships)
  • Number of collaborative community health needs assessments conducted to guide partnership efforts. (Measures data-driven planning for partnerships)
  • Number of communities leveraging partnerships to address non-medical influences on health. (Measures community-level impact of partnerships)
  • Number of health systems adopting community-based partnership models for improving population health. (Assesses uptake of partnerships in broader health systems)

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

  • Percent of policies established to support community-based care partnerships. (Assesses enabling factors for partnerships)
  • Percent of collaborative community health needs assessments conducted to guide partnership efforts. (Measures data-driven planning for partnerships)
  • Percent of communities leveraging partnerships to address non-medical influences on health. (Measures community-level impact of partnerships)
  • Percent of health systems adopting community-based partnership models for improving population health. (Assesses uptake of partnerships in broader health systems)

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] Contreras, S., Porras-Javier, L., Zima, B. T., Soares, N., Park, C., Patel, A., Chung, P. J., & Coker, T. R. (2018). Development of a Telehealth-Coordinated Intervention to Improve Access to Community-Based Mental Health. Ethnicity & disease, 28(Suppl 2), 457–466. https://doi.org/10.18865/ed.28.S2.457

[2] Germán, M., Alonzo, J. K., Williams, I. M., Bushar, J., Levine, S. M., Cuno, K. C., Umylny, P., & Briggs, R. D. (2023). Early Childhood Referrals by HealthySteps and Community Health Workers. Clinical pediatrics, 62(4), 321–328. https://doi.org/10.1177/00099228221120706

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.