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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Transition.

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Strategy. Medical Home Integration

Approach. Incorporate transition strategies into medical home systems

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Overview. Integrating healthcare transition planning into the medical home model represents a strategic approach to ensuring timely and comprehensive transition support for youth with special health care needs. Research has shown that the medical home model of care increases issue awareness and improves relationships within the healthcare system, with studies in multiple states indicating that medical home strategies "deserve careful consideration by leaders interested in transforming the system of care for CYSHCN."[1] When transition strategies are embedded into medical home workflows, they become a routine part of care rather than an afterthought, ensuring that transition planning occurs at developmentally appropriate times starting in early adolescence. The medical home's emphasis on coordinated, family-centered care aligns naturally with transition principles, creating opportunities for continuity across the pediatric-to-adult care transfer. Title V programs can support this integration by providing medical homes with transition-specific tools, workflows, and quality metrics, and by facilitating connections between pediatric and adult primary care practices. This systematic approach helps ensure that all youth receive consistent transition support regardless of their specific conditions or care settings.

Evidence. Expert Opinion. Strategies with this rating are recommended by credible, impartial experts...

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 on transition activities
  • Qualitative data from focus group implementing transition activities
  • Qualitative data from focus groups receiving transition activities

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

  • Policy. This strategy helps to promote decisions, laws, and regulations that promote public health practices and interventions.
  • Patient Experience of Care. This study improves individuals' perceptions, feelings, and satisfaction with the healthcare services they receive.
  • Access to/Receipt of Care. This strategy increases the ability for individuals to obtain healthcare services when needed, including preventive, diagnostic, and treatment 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. Policy Development and Enforcement (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 medical home practices that have integrated transition planning into their care model. (Measures adoption of transition strategies in medical homes)
  • Number of transition toolkits and resources distributed to medical home providers. (Measures dissemination of transition best practices)

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

  • Percent of medical home practices that have a written transition policy aligned with evidence-based frameworks. (Measures quality of transition strategy)
  • Percent of medical home providers who demonstrate proficiency in key transition competencies. (Measures workforce capacity to support transition)

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

  • Number of agreements established between pediatric and adult medical homes to coordinate transition care. (Measures cross-setting collaboration)
  • Number of providers in medical homes trained on caring for transitioning youth with complex health needs. (Measures workforce development on focus populations)
  • Number of youth transitioning from pediatric to adult medical homes with a shared plan of care. (Measures care coordination across settings)
  • Number of referrals made by medical homes to community-based organizations for transition supports. (Measures linkages to social services)

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

  • Percent of transition-age youth in the service population enrolled in a medical home, stratified by key demographics. (Measures access)
  • Percent of medical home teams with a plan to address social and emotional needs during transition. (Measures integration of health strategies)
  • Percent of transition-age medical home patients up-to-date on preventive screenings and immunizations. (Measures adherence to guidelines)
  • Percent of transitioning medical home patients with sustained continuity of care and information transfer to adult providers. (Measures systems outcomes)

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 AMCHP. November 2009. Models of Care Children and Youth with Special Health Care Needs:Promising Models for Transforming California's System of Care.

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.