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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Medical Home: Usual Source of Sick Care.

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Strategy. Care Transition Support

Approach. Support providers, patients and their caregivers to ensure smooth care transitions

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Overview. Navigating the transition between pediatric and adult healthcare systems can be challenging, particularly for CYSHCN, requiring specialized attention and coordination. Care transition support, often in the form of guidelines or tools, can address some of the challenges that young patients and their families face.[1] Without adequate support, children with and without special healthcare needs may face gaps in care that exacerbate health problems and hinder patients' ability to be independent.[1] Effective, well-planned care transitions can foster continuity, enhance access and improve communication between patients and providers.[1,2] Evidence suggests that the provision of tailored support through transitions is an important step in ensuring the success of young patients as they move from pediatric to adult care.[1]

Evidence. Mixed Evidence. Strategies with this rating have been tested more than once with results that sometimes trend positive...

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:

  • Care Transitions Measure (CTM-15) survey data
  • Follow-up appointment completion data
  • Provider communication and satisfaction data
  • Parent/caregiver/family satisfaction survey

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.
  • Timeliness of Care. This strategy promotes delivery of healthcare services in a timely manner to optimize benefits and prevent complications.
  • Quality of Care. This strategy promotes the degree to which healthcare services meet established standards aimed at achieving optimal health outcomes.

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. 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, patients, and caregivers receiving education from Title V on effective care transition practices. (Measures engagement of key partners in transition support)
  • Number of care transitions proactively planned and supported by designated care transition teams. (Assesses scope of care transition support activities)

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

  • Percent of care transitions involving comprehensive assessment and coordination among sending and receiving care teams. (Measures adherence to best practices in transition process)
  • Percent of patients and caregivers actively engaged in care transition planning and decision-making. (Assesses patient and family activation in transitions)

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

  • Number of patients and caregivers reporting high levels of preparedness and confidence in managing post-transition care. (Measures patient and caregiver capacity for successful transitions)
  • Number of care transitions meeting quality benchmarks for safety, effectiveness, and patient-centeredness. (Assesses quality of care transition process and outcomes)
  • Number of communities demonstrating significant reductions in care fragmentation through coordinated transition support interventions. (Measures system-level impact on care integration)
  • Number of healthcare organizations achieving improved patient outcomes and enhanced care team satisfaction through adoption of evidence-based transition support models. (Assesses organizational impact of transition investments)

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

  • Percent of care transition initiatives designed with input from patients and families most impacted by care fragmentation. (Measures community engagement in transition improvement efforts)
  • Percent of transition education and tools tailored to meet the needs and preferences of the communities sered. (Assesses responsiveness of transition strategies)
  • Percent reduction in differences in care transition quality and outcomes experienced by patients. (Measures impact on care transition outcomes)
  • Percent of patients and caregivers from various backgrounds reporting that transition support services are responsive to their self-determined priorities. (Assesses patient perceptions of dignity in care transitions)

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] Hart LC, Maslow G. The Medical Transition from Pediatric to Adult-Oriented Care: Considerations for Child and Adolescent Psychiatrists. Child Adolesc Psychiatr Clin N Am. 2018 Jan;27(1):125-132. doi: 10.1016/j.chc.2017.08.004. Epub 2017 Sep 21. PMID: 29157498.

[2] Kovacs AH, McCrindle BW. So hard to say goodbye: transition from paediatric to adult cardiology care. Nat Rev Cardiol. 2014 Jan;11(1):51-62. doi: 10.1038/nrcardio.2013.172. Epub 2013 Nov 12. PMID: 24217158.

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.