Find State ESMs

Measure Status: Active

Evidence Level: No similar strategy found in the established evidence for this NPM. See similar ESMs for this NPM or search for other strategies or promising practices.

Measurement Quadrant: Quadrant 1: Measuring quantity of effort (counts and "yes/no" activities)

Service Type: Systems level of pyramid

Essential Public Health Services: 8. Build and support a workforce

Service Recipient: Activities directed to professionals

Goal: Increase the percentage of families who have access to patient and family centered care coordination that respects the culture and primary language of the family to assist in integrating physical, oral and behavioral health issues into the care plan.

Numerator: The number of providers participating in QI around care coordination.

Denominator: Count

Significance:

Data Sources and Data Issues: Ideally, medical home care is delivered within the context of a trusting and collaborative relationship between the child’s family and a competent health professional familiar with the child and family and the child’s health history. Pediatric clinicians in New Mexico who have effective policies and procedures in place to provide effective integration of physical health, oral and behavioral health care and have an effective method for cross-provider communication are needed to increase the percentage of children with a medical home. The QI initiative will increase the likelihood that pediatric providers utilize the appropriate policies and procedures.

Year: 2021

Unit Type: 100, Unit Number: The CMS QI initiative roll.

Measure Status: Active

Evidence Level: No similar strategy found in the established evidence for this NPM. See similar ESMs for this NPM or search for other strategies or promising practices.

Measurement Quadrant: Quadrant 1: Measuring quantity of effort (counts and "yes/no" activities)

Service Type: Enabling services level of pyramid

Essential Public Health Services: 7. Assure effective and equitable health systems

Service Recipient: Activities directed to families/children/youth

Goal: Increase the number of families served by the program.

Numerator: Count

Denominator: 3000

Significance:

Data Sources and Data Issues:

Year: 2021

Unit Type: Administrative data from the Family Care Enhancement Project, Unit Number: Parent Resource Coordination aims to increase access to, and the provision of Medical Homes, through improvements in patient and family centered care.

Measure Status: Active

Evidence Level: No similar strategy found in the established evidence for this NPM. See similar ESMs for this NPM or search for other strategies or promising practices.

Measurement Quadrant: Quadrant 2: Measuring quality of effort (% of reach; satisfaction)

Service Type: Direct services level of pyramid

Essential Public Health Services: 7. Assure effective and equitable health systems

Service Recipient: Activities directed to families/children/youth

Goal: By September 2025, 40% of shared care plans will have a representative of primary care help LPHAs prepare for or participate in shared care planning meetings.

Numerator: Number of shared care plans with a primary care representative assisting the LPHA to prepare for, or participating in, a new or re-evaluation shared care planning meeting in a given year.

Denominator: Number of shared care plans in the same year.

Significance: The National Standards for Systems of Care for CYSHCN identify pediatric primary care as the locus for care coordination for CYSHCN, although recognize that teams of professionals partner with families to provide care to CYSHCN. Not all Oregon primary care clinics well provide care coordination for CYSHCN and their families, and not all primary care-based care coordinators well coordinate care across systems. Given their community connections, local public health authorities can support primary care practices in cross-systems care coordination but need primary care to engage in the team-based work. This measure helps us monitor whether and how primary care engages in one of our cross-systems care coordination strategies.

Data Sources and Data Issues: The data source for this ESM is the Shared care plan Information Form (SIF), which is a data collection administered by OCCYSHN. LPHAs complete a SIF after each shared care planning meeting. OCCYSHN contracts require LPHA participation in this data collection and requests that LPHAs complete their SIF within two weeks of a shared care planning meeting. We established objectives at the time of block grant writing (June 2020). We are still learning how COVID-19 is affecting LPHAs ability to implement shared care planning and, as a result, may have to adjust our objectives in the future.

Year: 2021

Unit Type: Percentage, Unit Number: 100

Measure Status: Active

Evidence Level: Emerging. Aligns with MCHbest strategy "Provider Alliance and Mid-Level Providers". Find other NPM 11 patient/family-level strategies in MCHbest.

Measurement Quadrant: Quadrant 4: Measuring quality of effect (% of "is anyone better off")

Service Type: Direct services level of pyramid

Essential Public Health Services: 7. Assure effective and equitable health systems

Service Recipient: Activities directed to families/children/youth

Goal: The goal is to increase access to peer support available through the CNMI Family to Family Health Information Center for parents to receive information and assistance on accessing a medical home in the CNMI.

Numerator: Number of families served by the Family to Family Health Information Center who reported having a medical home.

Denominator: Number of families served by Family to Family Health Information Center.

Significance: Family Peer Support is the instrumental, social and informational support provided from one parent to another in an effort to reduce isolation, shame and blame, to assist parents in navigating child serving systems, including access to medical homes.

Data Sources and Data Issues: Data will be obtained through program administrative records/referral forms.

Year: 2021

Unit Type: Percentage, Unit Number: 100

Measure Status: Active

Evidence Level: No similar strategy found in the established evidence for this NPM. See similar ESMs for this NPM or search for other strategies or promising practices.

Measurement Quadrant: Quadrant 2: Measuring quality of effort (% of reach; satisfaction)

Service Type: Systems level of pyramid

Essential Public Health Services: 8. Build and support a workforce

Service Recipient: Activities directed to professionals

Goal: To promote appropriate communication from pediatric providers regarding abnormal NBS test results and findings to families

Numerator: Number of SC AAP members who complete training

Denominator: Total number of SC AAP members

Significance: Needs assessment results show that communication from providers regarding abnormal newborn screenings to families is lacking and needs improvement.

Data Sources and Data Issues: MCH Program in collaboration with multi-sector partners

Year: 2021

Unit Type: Percentage, Unit Number: 100

Measure Status: Active

Evidence Level: No similar strategy found in the established evidence for this NPM. See similar ESMs for this NPM or search for other strategies or promising practices.

Measurement Quadrant: Quadrant 4: Measuring quality of effect (% of "is anyone better off")

Service Type: Systems level of pyramid

Essential Public Health Services: 8. Build and support a workforce

Service Recipient: Activities directed to professionals

Goal: 80% of Regional Center information and referral staff, who have been in their position for one year or more, will self-evaluate at a minimum of 50% “competent” or “proficient” in Medical Home competencies.

Numerator: Number of Regional Center information and referral staff, who have been in their position for one year or more, who self-evaluate at a minimum of 50% “competent” or “proficient” in Medical Home competencies

Denominator: Number of Regional Center information and referral staff who have been in their position for one year or more who complete a self-evaluation

Significance: Because Regional Centers for CYSHCN serve in a leadership capacity in their region to promote the use of Medical Home tools and common messages with regional and community partners (local and tribal health agencies, home visiting programs, and others) it is critical that they have the necessary knowledge of Medical Home concepts. In an effort to maintain a competent Regional Center work force related to Medical Home concepts, the CYSHCN Program, with the Wisconsin Medical Home Initiative, developed a Medical Home self-assessment. At the beginning of 2021, all Regional Center information and referral staff will complete the Medical Home self-assessment. The results of this self-assessment will guide staff training and onboarding.

Data Sources and Data Issues: Qualtrics tracking system will be used. The system was piloted in 2020 and no issues are anticipated.

Year: 2021

Unit Type: Percentage, Unit Number: 100

Measure Status: Active

Evidence Level: No similar strategy found in the established evidence for this NPM. See similar ESMs for this NPM or search for other strategies or promising practices.

Measurement Quadrant: Quadrant 4: Measuring quality of effect (% of "is anyone better off")

Service Type: Systems level of pyramid

Essential Public Health Services: 8. Build and support a workforce

Service Recipient: Activities directed to professionals

Goal: Implement Technical Assistance Training fo providers at least twice a year to improve competencies in screening, referral and health care management of Children with Speical Health Care Needs

Numerator: Number of providers attending both trainings and report they feel more confident in serving Children with Special Health Care Needs.

Denominator: Total number of providers who serve children and families.

Significance: Significance The Title V Maternal and Child Health Services Block Grant to States Program guidance defines the significance of this goal as follows: The American Academy of Pediatrics (AAP) specifies seven qualities essential to medical home care: accessible, family-centered, continuous, comprehensive, coordinated, compassionate and culturally effective. Ideally, medical home care is delivered within the context of a trusting and collaborative relationship between the child's family and a competent health professional familiar with the child and family and the child's health history. Providing comprehensive care to children in a medical home is the standard of pediatric practice. Research indicates that children with a stable and continuous source of health care are more likely to receive appropriate preventive care and immunizations, are less likely to be hospitalized for preventable conditions, and are more likely to be diagnosed early for chronic or disabling conditions. The Maternal and Child Health Bureau uses the AAP definition of medical home.

Data Sources and Data Issues: MCH Title V

Year: 2021

Unit Type: Percentage, Unit Number: 100

Measure Status: Active

Evidence Level: Emerging. Aligns with MCHbest strategy "Dedicated Care Coordinators". Find other NPM 12 patient/practice-level strategies in MCHbest.

Measurement Quadrant: Quadrant 4: Measuring quality of effect (% of "is anyone better off")

Service Type: Direct services level of pyramid

Essential Public Health Services: 7. Assure effective and equitable health systems

Service Recipient: Activities directed to families/children/youth

Goal: To increase the percent of families who received effective care coordination.

Numerator: Number of families who received effective care coordination.

Denominator: Number of families who were sampled.

Significance: The American Academy of Pediatrics (AAP) specifies seven qualities essential to medical home care: accessible, family-centered, continuous, comprehensive, coordinated, compassionate and culturally effective. Ideally, medical home care is delivered within the context of a trusting and collaborative relationship between the child’s family and a competent health professional familiar with the child and family and the child’s health history. Providing comprehensive care to children in a medical home is the standard of pediatric practice. Research indicates that children with a stable and continuous source of health care are more likely to receive appropriate preventive care and immunizations, are less likely to be hospitalized for preventable conditions, and are more likely to be diagnosed early for chronic or disabling conditions. The Maternal and Child Health Bureau uses the AAP definition of medical home.

Data Sources and Data Issues: National Survey of Children's Health (NSCH)

Year: 2021

Unit Type: Percentage, Unit Number: 100

Measure Status: Active

Evidence Level: Emerging. Aligns with MCHbest strategy "Dedicated Care Coordinators". Find other NPM 11 in MCHbest.

Measurement Quadrant: Quadrant 2: Measuring quality of effort (% of reach; satisfaction)

Service Type: Enabling services level of pyramid

Essential Public Health Services: 7. Assure effective and equitable health systems

Service Recipient: Activities directed to families/children/youth

Goal: Assess care coordination to evaluate the assistance families receive with medical home services and inform efforts to support provision of medical home services for CYSHCN.

Numerator: Number of CYSHCN families surveyed who indicated they received professional care coordination for their child

Denominator: Total number of CYSHCN families surveyed

Significance: The 2002 AAP Policy Statement on Medical Home defined care within a medical home as accessible, family-centered, continuous, comprehensive, coordinated, compassionate and culturally effective. The Joint Principles of the Patient Centered Medical Home defined these characteristics through seven principles including care coordination across all elements of the complex health care system and community. The National Survey of Children’s Health (NSCH) 2016/18 identified that 43.4% of Texas CYSHCN met all criteria for the medical home outcome, and less than one third received any help with arranging or coordinating care. Findings from the Title V Five Year Needs Assessment support that coordination of care is a challenge. The 2019 CYSHCN Outreach Survey, gathered as part of the Title V 2020 Needs Assessment, showed 61.8% of respondents reported that they coordinate their child’s care themselves. Survey data also showed that 27.8% of respondents received professional help from someone at the child’s doctor’s office, a case manager or social worker, or someone at the child’s school with care coordination services. Successful provider education, outreach, and promotion of medical home best practices will lead to increased implementation skills related to providing quality care coordination for CYSHCN and families.

Data Sources and Data Issues: Data Source: CYSHCN Outreach Survey Responses to the CYSHCN Outreach Survey are collected on a biennial basis. The survey is mailed out and dispersed electronically to families served by the HHSC CSHCN health care benefits program and MCHS contractors in both English and Spanish formats. The survey will be promoted through email communication, newsletters, and webpages. According to results of the 2019 CYSHCN Outreach Survey as part of the 2020 Title V Five Year Needs Assessment, 203 of 730 survey respondents (27.8%) indicated they received professional help from someone at the child’s doctor’s office, a case manager or social worker, or someone at the child’s school with care coordination services. Data Issues: Challenges associated with surveying a convenience sample include the potential to underrepresent subsets of the CYSHCN population in Texas according to geographical location or language spoken. The CYSHCN Outreach Survey seeks to combat these challenges by providing both online and paper access to the survey in English and Spanish. Geographical data is also gathered in order to examine relevant needs assessment activities.

Year: 2021

Unit Type: Percentage, Unit Number: 100

Measure Status: Active

Evidence Level: Emerging. Aligns with Dedicated Care. Find other NPM 11 Dedicated Care-level strategies in MCHbest.

Measurement Quadrant: Quadrant 4: Measuring quality of effect (% of "is anyone better off")

Service Type: Direct services level of pyramid

Essential Public Health Services: 7. Assure effective and equitable health systems

Service Recipient: Activities directed to families/children/youth

Goal: Ensure an enhanced care coordination system at the CSHCNP to improve the health care accessibility and integrated services for CSHCN, and to support the development of the medical home community at the seven health regions of the island.

Numerator: Number of families at the CSHCN Program who report that they have “always” a care coordinator assigned to help them find the services they need.

Denominator: Number of families at the CSHCN Program who participated in the Medical Home Family Index Survey (adapted).

Significance: Care coordination has been identified as an important way to improve how the healthcare system works, especially for CSHCN, and to increase the potential for better outcomes for CSHCN, providers, and payers. Care coordination is a core component of the medical home model for CSHCN.

Data Sources and Data Issues: Medical Home Family Index Survey (adapted) at the PR-CSHCN Program.

Year: 2021

Unit Type: Percentage, Unit Number: 100

Measure Status: Active

Evidence Level: No similar strategy found in the established evidence for this NPM. See similar ESMs for this NPM

Measurement Quadrant: Quadrant 4: Measuring quality of effect (% of "is anyone better off")

Service Type: Systems level of pyramid

Essential Public Health Services: 3. Inform and educate the public

Service Recipient:

Goal: To increase health care knowledge of youth, families, and healthcare providers on a variety of health topics, through targeted presentations.

Numerator: Number of youth, family members, health care providers and community professionals who complete trainings and report increased knowledge.

Denominator: Number of youth, family members, health care providers and community professionals who complete trainings for the first time and return an evaluation form.

Significance: This ESM seeks to improve engagement in healthcare services, by offering CYSHCN, families, and health care providers’ increased knowledge on a variety of health care topics. Presentations for CYSHCN and families seek to increase knowledge and awareness about resources and tools needed to access healthcare services. While presentations for healthcare providers, aims to increase awareness of specific needs of CYSHCN and how to better engage them in care, especially around adolescent healthcare transition. This ESM aims to increase the NPM of increasing utilization of Medical Homes, by helping CYSHCN, families, and healthcare providers better understand the processes involved to regularly seek preventive and essential care.

Data Sources and Data Issues: Presentation evaluations and/or pre- and post- questions. Inconsistencies between data sources will need to be managed. Assessments/evaluations will need to include either a practical assessment of knowledge change, or a self-report, and first-time attendance will need to be tracked or self-reported. The total number of individuals trained will be reported in field notes since the numerator/denominator is limited only to those who returned evaluations.

Year: 2021

Unit Type: Percentage, Unit Number: 100

Measure Status: Active

Evidence Level: This ESM measures access to/receipt of care, thus doesn't align with a specific evidence-based strategy. Consider developing an ESM for one of the specific strategies in your state action plan to measure performance. Check MCHbest for examples to connect to the evidence.

Measurement Quadrant: Quadrant 4: Measuring quality of effect (% of "is anyone better off")

Service Type: Direct services level of pyramid

Essential Public Health Services: 7. Assure effective and equitable health systems

Service Recipient: Activities directed to families/children/youth

Goal: Increase the percentage of CYSHCN receiving care coordination services (beyond simple information and referral) through the Connecticut Medical Home Initiative for CYSHCN (CMHI) who have a comprehensive care plan in place.

Numerator: # of CYSHCN receiving care coordination through CMHI with a comprehensive care plan documented in the MAVEN reporting database

Denominator: # of CYSHCN receiving care coordination through CMHI documented in the MAVEN reporting database

Significance: The American Academy of Pediatrics (AAP) proposed a definition of the medical home in a 1992 policy statement. A 2002 AAP statement contained an expanded and more comprehensive interpretation of the concept and an operational definition of the medical home. The AAP developed the medical home as a model of delivering primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective to every child and adolescent. A pediatric medical home is a family-centered partnership within a community-based system that provides uninterrupted care with appropriate payment to support and sustain optimal health outcomes and is a standard to maintain in a well-functioning system for Children & Youth with Special Health Care Needs (CYSHCN). The 2015 National Committee for Quality Assurance (NCQA) Patient-Centered Medical Homes (PCMH) Evidence Report indicates that PCMHs are saving money by reducing hospital and emergency department visits, reducing health disparities, and improving patient outcomes. The Connecticut Medical Home Initiative (CMHI) works to expand the number of NCQA level 2 and 3 recognized medical homes in CT. DPH conducts a Family Medical Home Survey on an ongoing basis as a validation of data reported by care coordinators to include questions regarding family involvement in care planning.

Data Sources and Data Issues: DPH Connecticut Medical Home Initiative Care Coordination MAVEN database. DPH care coordination contractual program statistical reports. DPH conducted Family Medical Home Survey.

Year: 2021

Unit Type: Percentage, Unit Number: 100

Measure Status: Active

Evidence Level: Aligns with MCHbest strategy "Dedicated Care Coordinator." Find other NPM 11 strategies in MCHbest.

Measurement Quadrant: Quadrant 4: Measuring quality of effect (% of "is anyone better off")

Service Type: Enabling services level of pyramid

Essential Public Health Services: 7. Assure effective and equitable health systems

Service Recipient: Activities directed to families/children/youth

Goal: Increase number of CYSHCN receiving services from a Parent Partner in FFY 2021.

Numerator: Number of CYSHCN receiving services from a Parent Partner in FFY21 divided by the number of CYSHN receiving services from a Parent Partner in FFY20.

Denominator: Number of CYSHCN receiving services from a parent partner in FFY20.

Significance: The definition for numerator was modified to accurately capture the equation needed to determine percent increase of CYSHCN served. The Montana Parent Partner Program will continue to expand in FFY21 and FFY 22 through increased operational efficiency and performance monitoring metrics. Parent Partners assist families with the 'non-medical' parts of the medical home, helping them to access much needed services and supports in their communities

Data Sources and Data Issues: Child Health Referral Information System (CHRIS) and Montana NSCH Data

Year: 2021

Unit Type: Percentage, Unit Number: 100

Measure Status: Active

Evidence Level: Emerging. Aligns with MCHbest strategy “Dedicated Care Coordinators”. Find other NPM 11 strategies in MCHbest.

Measurement Quadrant: Quadrant 4: Measuring quality of effect (% of "is anyone better off")

Service Type: Direct services level of pyramid

Essential Public Health Services: 7. Assure effective and equitable health systems

Service Recipient: Activities directed to families/children/youth

Goal: Having a PCP is a 1st step in building a medical home for CYSHCN. ESM 11.1 provides a baseline for programmatic needs to increase % of CYSHCN with a PCP and identify next steps of medical home for CYSHCN. SPoC was added to ESM 11.1 for MCHBG 2019.

Numerator: Number of CYSHCN ages 0-18 years served by SCHS CMUs with a primary care physician and/or SPoC

Denominator: Number of CYSHCN ages 0-18 years served by SCHS CMUs

Significance: The first principle of the Joint Principles of the Patient Centered Medical Home is that a CYSHCN has a personal physician who is “trained to provide first contact, continuous and comprehensive care.” ESM #11.1 is the ‘first step’ in establishing and building a medical home. Research indicates that children with a stable and continuous source of health care are more likely to receive appropriate preventive care and immunizations, are less likely to be hospitalized for preventable conditions, and are more likely to be diagnosed early for chronic or disabling conditions.

Data Sources and Data Issues: The data source is a statewide electronic documentation system used by all 21 county SCHS CMUs. The Case Management Referral System (CMRS) is used to track and monitor services provided to CYSHCN and their families. Included in CMRS is the ability to create and modify an Individual Service Plan (ISP), track services, and create a record of each contact with the child and child's family. The primary limitation of the data is that it is limited to CYSHCN served by SCHS CMUs (i.e., excludes children without special health care needs and CYSHCN not served by SCHS CMUs).

Year: 2021

Unit Type: Percentage, Unit Number: 100

Measure Status: Active

Evidence Level: This ESM is population-based (measures access to/receipt of care), thus doesn’t align with a specific evidence-based strategy. Consider developing an ESM for one of the specific strategies in your state action plan to measure performance. Check MCHbest for examples to connect to the evidence.

Measurement Quadrant: Quadrant 2: Measuring quality of effort (% of reach; satisfaction)

Service Type: Systems level of pyramid

Essential Public Health Services: 8. Build and support a workforce

Service Recipient: Activities directed to professionals

Goal: Increase the percentage of identified CSHCN provided with a medical home

Numerator: Number of CSHCN providers and parents/caregivers received components of the medical home training

Denominator: The total number of CHSCN providers and parents/caregivers during the reporting year.

Significance: Training and care coordination leads to a well functioning system of care for CSHCN and their parents and care givers.

Data Sources and Data Issues: CSHCN Registry

Year: 2021

Unit Type: Percentage, Unit Number: 100

Measure Status: Active

Evidence Level: There is limited research in the evidence base for this NPM to support this strategy.

Measurement Quadrant: Quadrant 4: Measuring quality of effect (% of "is anyone better off")

Service Type: Enabling services level of pyramid

Essential Public Health Services: 4. Support and mobilize partners

Service Recipient: Activities directed to families/children/youth

Goal: Develop CSH advisory council with at least 50% of members having lived experience (e.g. being a parent of a child with special health care needs)

Numerator: Number of advisory council members with lived experience

Denominator: Total number of advisory council members

Significance: This ESM (and associated activity) helps the program to prioritize family partnership in improving systems of care for CSHCN.

Data Sources and Data Issues: CSHCN Program Data

Year: 2021

Unit Type: Percentage, Unit Number: 100

Measure Status: Active

Evidence Level: No similar strategy found in the established evidence for this NPM. See similar ESMs for this NPM or search for other strategies or promising practices.

Measurement Quadrant: Quadrant 4: Measuring quality of effect (% of "is anyone better off")

Service Type: Direct services level of pyramid

Essential Public Health Services: 7. Assure effective and equitable health systems

Service Recipient: Activities directed to families/children/youth

Goal: By 2025, increase the percent of CSHCN who received family-centered care to 90%

Numerator: Number of CSHCN ages 0 through 17 that received family-centered care

Denominator: Number of CSHCN ages 0 through 17

Significance: The American Academy of Pediatrics (AAP) specifies seven qualities essential to medical home care, which include accessible, family-centered, continuous, comprehensive, coordinated, compassionate and culturally effective. Providing comprehensive and coordinated care to children in a medical home is the standard of pediatric practice. Research indicates that children with a stable and continuous source of health care are more likely to receive appropriate preventive care, are less likely to be hospitalized for preventable conditions, and are more likely to be diagnosed early for chronic or disabling conditions. The Maternal and Child Health Bureau uses the AAP definition of medical home. www.medicalhomeinfo.aap.org In the NSCH, family-centered care is comprised of responses to five experience-of-care questions: [provider] spends enough time with child, listens carefully to you, is sensitive to family values/customs, gives needed information , and family feels like partner.

Data Sources and Data Issues: National Survey of Children's Health (NSCH)

Year: 2021

Unit Type: Percentage, Unit Number: 100

Measure Status: Active

Evidence Level: No similar strategy found in the established evidence for this NPM. See similar ESMs for this NPM or search for other strategies or promising practices.

Measurement Quadrant: Quadrant 4: Measuring quality of effect (% of "is anyone better off")

Service Type: Direct services level of pyramid

Essential Public Health Services: 7. Assure effective and equitable health systems

Service Recipient: Activities directed to families/children/youth

Goal: Increase family-centered care among children ages 0-17 years with special health care needs who receive family-centered school from 86.9% (2017-2018) to 91.2% (2025).

Numerator: Number of children with special health care needs ages 0 through 17 years who had a health care visit in the past 12 years and received family-centered care

Denominator: Number of children with special health care needs ages 0 through 17 years who had a health care visit in the past 12 years

Significance: When our policies, systems, and providers use the family-centered approach, families are more likely to access meaningful supports & services, thereby creating environments where families are engaged, involved, and supported. Strategies will focus on investing in and influencing people, process and technology to adopt family-centered practices to increase equitable access to and use of specialty care; enhance provider and system capacity to bridge healthcare and other partners; support communication and collaboration between community-based programs and partners; and use data to identify, illuminate, and address access, utilization, and outcome inequities.

Data Sources and Data Issues: National Survey of Children’s Health

Year: 2021

Unit Type: Percentage, Unit Number: 100

Measure Status: Active

Evidence Level: This ESM is population-based (measures access to/receipt of care), thus doesn’t align with a specific evidence-based strategy. Consider developing an ESM for one of the specific strategies in your state action plan to measure performance. Check MCHbest for examples to connect to the evidence.

Measurement Quadrant: Quadrant 4: Measuring quality of effect (% of "is anyone better off")

Service Type: Direct services level of pyramid

Essential Public Health Services: 7. Assure effective and equitable health systems

Service Recipient: Activities directed to families/children/youth

Goal: To ensure that all children with or without special healthcare needs are able to identify a medical home

Numerator: 9758

Denominator: 27026

Significance: Meeting the needs of the targeted population

Data Sources and Data Issues: Jurisdictional Survey

Year: 2021

Unit Type: Percentage, Unit Number: 100

Measure Status: Active

Evidence Level: Emerging. Aligns with MCHbest strategy "Dedicated Care Coordinators". Find other NPM 11 family-level strategies in MCHbest.

Measurement Quadrant: Quadrant 4: Measuring quality of effect (% of "is anyone better off")

Service Type: Enabling services level of pyramid

Essential Public Health Services: 7. Assure effective and equitable health systems

Service Recipient: Activities directed to families/children/youth

Goal: Improve access to care and services for CYSHCN by measuring the effectiveness of the Sanford Care Coordination Program.

Numerator: # of families enrolled in care coordination services who report an improvement in obtaining needed referrals to care and/or services

Denominator: # of families enrolled in care coordination services

Significance: The AAP specifies seven qualities essential to medical home care: accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally effective. Ideally, medical home care is delivered within the context of a trusting and collaborative relationship between the child's family and a competent health professional familiar with the child and family and the child's health history. Providing comprehensive care to children in a medical home is the standard pediatric practice. Research indicates that children with a stable and continuous source of health care are more likely to receive appropriate preventive care and immunizations, are less likely to be hospitalized for preventable conditions, and are more likely to be diagnosed early for chronic or disabling conditions.

Data Sources and Data Issues: pre-care coordination and post-care coordination surveys of clients provided by South Dakota State University Population Health

Year: 2021

Unit Type: Percentage, Unit Number: 100