Find State ESMs

Measure Status: Active

Evidence Level: No similar strategy found in the established evidence for this NPM. See similar ESMs (https://www.mchlibrary.org/evidence/state-esms-results.php?q=quality+improvement&NPM=11&State=&RBA_Category=&MCH_Pyramid=&Recipient=&Status=Active) for this NPM or search for other strategies or promising practices (https://www.mchevidence.org/tools/npm/11-medical-home.php).

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

Service Type: Public health services and 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: N/A

Significance: 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.

Data Sources and Data Issues: The CMS QI initiative roll.

Year: 2020

Unit Type: Simple Count, Unit Number: 100

Measure Status: Active

Evidence Level: No similar strategy found in the established evidence for this NPM. See similar ESMs (https://www.mchlibrary.org/evidence/state-esms-results.php?q=parent+support&NPM=11&State=&RBA_Category=&MCH_Pyramid=&Recipient=&Status=Active) for this NPM or search for other strategies or promising practices (https://www.mchevidence.org/tools/npm/11-medical-home.php).

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: NA

Denominator: NA

Significance: Parent Resource Coordination aims to increase access to, and the provision of Medical Homes, through improvements in patient and family centered care.

Data Sources and Data Issues: Administrative data from the Family Care Enhancement Project

Year: 2020

Unit Type: Simple Count, Unit Number: 3,000

Measure Status: Active

Evidence Level: No similar strategy found in the established evidence for this NPM. See similar ESMs (https://www.mchlibrary.org/evidence/state-esms-results.php?q=shared+plan+of+care&NPM=11&State=&RBA_Category=&MCH_Pyramid=&Recipient=&Status=Active) for this NPM or search for other strategies or promising practices (https://www.mchevidence.org/tools/npm/11-medical-home.php).

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

Service Type: Public health services and systems level of pyramid

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

Service Recipient: Activities related to systems-building

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: 2020

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 on NPM8 to connect to the evidence.

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

Service Type: Public health services and systems level of pyramid

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

Service Recipient: Activities related to systems-building

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: 2020

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 (https://www.mchlibrary.org/evidence/state-esms-results.php?q=training&NPM=10&State=&RBA_Category=&MCH_Pyramid=&Recipient=Activities+directed+to+professionals&Status=Active) for this NPM or search for other strategies or promising practices (https://www.mchevidence.org/tools/npm/11-medical-home.php).

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

Service Type: Public health services and systems level of pyramid

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

Service Recipient: Activities related to systems-building

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: 2020

Unit Type: Percentage, Unit Number: 100

Measure Status: Active

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

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

Service Type: Public health services and systems level of pyramid

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

Service Recipient: Activities related to systems-building

Goal: To increase the percentage of family satisfaction with access to care received in a patient-centered medical home and/or primary care for children that have special health care needs.

Numerator: Percent of families reporting at least an 80% satisfaction rate

Denominator: All families surveyed

Significance: Patient experience is main component of achieving high-quality care. Systematic review of studies demonstrates positive association between patient experience and clinical effectiveness and patient safety, decreasing health care costs. The identified priority need included primary care, and not just patient-centered medical home, which necessitated the inclusion of this in the measure. The results of this measure will help drive quality improvement activities, driven by family input, to improve access.

Data Sources and Data Issues: Survey: University Florida Institute for Child Health Policy

Year: 2020

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 (https://www.mchlibrary.org/evidence/state-esms-results.php?q=provider+training&NPM=11&State=&RBA_Category=&MCH_Pyramid=&Recipient=Activities+directed+to+professionals&Status=Active) for this NPM or search for other strategies or promising practices (https://www.mchevidence.org/tools/npm/11-medical-home.php).

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

Service Type: Public health services and 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: 2020

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 (https://www.mchlibrary.org/evidence/state-esms-results.php?q=educat&NPM=11&State=&RBA_Category=&MCH_Pyramid=&Recipient=Activities+directed+to+families%2Fchildren%2Fyouth&Status=Active) for this NPM or search for other strategies or promising practices (https://www.mchevidence.org/tools/npm/11-medical-home.php).

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 professionals

Goal: Increase the percent of providers who educate their patients (CSHCN parents) on the importance of having a medical home.

Numerator: # of providers who respond affirmatively about educating CSHCN families on medical home, when surveyed by stakeholder work group.

Denominator: # providers surveyed by stakeholder work group who respond to survey.

Significance: The medical home model promotes high quality primary care that promotes coordination and partnership between the family, the patient, and health care and other service providers. The percent of providers who understand and promote the medical home concept is a marker of a well functioning and coordinated system of care for CSHCN.

Data Sources and Data Issues: CSHCN stakeholder workgroup survey

Year: 2020

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 (https://www.mchlibrary.org/evidence/state-esms-results.php?q=provider+training&NPM=11&State=&RBA_Category=&MCH_Pyramid=&Recipient=&Status=Active) for this NPM or search for other strategies or promising practices (https://www.mchevidence.org/tools/npm/11-medical-home.php).

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

Service Type: Public health services and 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: 2020

Unit Type: Percentage, Unit Number: 100

Measure Status: Active

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

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

Service Type: Public health services and systems level of pyramid

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

Service Recipient: Activities directed to professionals

Goal: Increase the percent of providers who indicate they provide a medical home to patients with autism in the ECHO Projects survey.

Numerator: The number of providers who rate themselves confident or very confident that they are able to provide a medical home for their patients with autism.

Denominator: The total number of respondents who complete the question on the survey

Significance: As communities around Washington work to meet the need of families with CYSHCN with autism, there have been gaps identified in diagnostic and referral process—particularly around who is recognized by Medicaid to provide billable diagnosis and referral services to CYSHCN with ASD/DD. This places the burden on primary care providers who may not have the expertise to diagnose autism, or who are not recognized by Washington’s Medicaid agency as having the necessary expertise to diagnose and refer to autism specialty services. Often the providers themselves lack confidence in providing a medical home to children with ASD/DD when they lack access to consultations with qualified professionals to meet the often challenging needs of this population. The Health Care Authority (HCA) funds a 1.5 day Center of Excellence training with faculty from Seattle Children’s and UW LEND to increase the number of PCPs who are recognized by the HCA to diagnose autism and refer children for HCA-covered treatment. COE PCPs interested in further developing their autism diagnostic and management skills can apply to join a UW LEND led year-long Project ECHO Autism WA cohort with twice a month Zoom videoconferencing case-based learning, consultation and didactics. The DOH-funded UW Medical Home Partnerships Project for CYSHCN participates in both the COE training and Project ECHO Autism helping connect providers to community colleagues and resources.

Data Sources and Data Issues: The ECHO Project uses a redcap survey based on the survey developed by the University of Missouri’s Project ECHO Autism. All primary care providers who have taken the Center of Excellence training and signed up to be COEs, and those COEs engaged in Project ECHO Autism are asked each year to complete the survey. This survey is repeated yearly, starting March 2020, to gauge increase in provider confidence in implementing their skills in diagnosing, treating and referring children with autism in a family- centered Medical Home. Data Issues: Survey is self-administered. Terms are not independently defined.

Year: 2020

Unit Type: Percentage, Unit Number: 100

Measure Status: Active

Evidence Level: Emerging. Aligns with MCHbest strategy "Dedicated Care Coordinators" (https://www.mchevidence.org/tools/strategies/11-2.php). Find other NPM 12 patient/practice-level strategies in MCHbest. (note: xxx should be the audience field in MCHbest)

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

Service Type: Public health services and systems level of pyramid

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

Service Recipient: Activities related to systems-building

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: 2020

Unit Type: Percentage, Unit Number: 100

Measure Status: Active

Evidence Level: Emerging. Aligns with MCHbest strategy "Dedicated Care Coordinators" (https://www.mchevidence.org/tools/strategies/11-2.php). Find other NPM 11 practice-level strategies 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: 2020

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: Public health services and systems level of pyramid

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

Service Recipient: Activities related to systems-building

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: 2020

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 (https://www.mchlibrary.org/evidence/state-esms-results.php?q=shared+plan+of+care&NPM=11&State=&RBA_Category=&MCH_Pyramid=&Recipient=&Status=Active) for this NPM or search for other strategies or promising practices (https://www.mchevidence.org/tools/npm/11-medical-home.php).

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

Service Type: Public health services and systems level of pyramid

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

Service Recipient: Activities related to systems-building

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 Simple 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: 2020

Unit Type: Percentage, Unit Number: 100

Measure Status: Active

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

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

Service Type: Public health services and systems level of pyramid

Essential Public Health Services: 4. Support and mobilize partners

Service Recipient: Activities directed to professionals

Goal: Medical Home is a health care delivery model coordinated through the primary care physician (PCP) to ensure the necessary health care. For CSHCN, their pediatrician is typically their PCP. The goal is to increase communication between PCPs and RPCs h

Numerator: Number of PCPs who report they received feedback from RPC health staff concerning the referred child.

Denominator: Number of referrals

Significance: CSHCN typically need an extensive variety of health care services. Collaboration among the different health care providers, particularly the PCP, will enhance integrated care in the context of a patient’s overall health care needs. This requires efficient communication systems among health care providers. A survey carried out in 2017 with 87 local pediatricians indicated the need for better communication with health care providers who treat their referred CSHCN. Communication among health care providers and PCPs may increase the awareness of each other’s type of knowledge and skills, which can lead to continuous improvement in decision-making and to an enhanced medical home.

Data Sources and Data Issues: Data source: RPCs’ daily census. Meetings with RPCs’ directors and staff will be conducted to identify and implement strategies to collect information. Data issues: The collection of data for the numerator may face challenges as it will depend on PCPs’ contact availability. With this protocol/procedure, new strategies to increase communication among health care providers will be identified.

Year: 2020

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: 2020

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 (https://www.mchlibrary.org/evidence/state-esms-results.php?q=family-centered+care&NPM=11&State=&RBA_Category=&MCH_Pyramid=&Recipient=&Status=Active) for this NPM or search for other strategies or promising practices (https://www.mchevidence.org/tools/npm/11-medical-home.php).

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

Service Type: Public health services and systems level of pyramid

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

Service Recipient: Activities related to systems-building

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: 2020

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 (https://www.mchlibrary.org/evidence/state-esms-results.php?q=family-centered+care&NPM=11&State=&RBA_Category=&MCH_Pyramid=&Recipient=&Status=Active for this NPM or search for other strategies or promising practices (https://www.mchevidence.org/tools/npm/11-medical-home.php).

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

Service Type: Public health services and systems level of pyramid

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

Service Recipient: Activities related to systems-building

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: 2020

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: Public health services and systems level of pyramid

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

Service Recipient: Activities related to systems-building

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: 2020

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 (https://www.mchlibrary.org/evidence/state-esms-results.php?q=medical+home+portal&NPM=11&State=&RBA_Category=&MCH_Pyramid=&Recipient=&Status=Active) for this NPM or search for other strategies or promising practices (https://www.mchevidence.org/tools/npm/11-medical-home.php).

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

Service Type: Public health services and systems level of pyramid

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

Service Recipient: Activities directed to families/children/youth

Goal: Increase the number of web hits on medical home portal from 1781 to 20,000 by 2025

Numerator: # web hits on RIDOH medical home portal https://ri.medicalhomeportal.org/

Denominator: N/A

Significance: A 2017 NCQA report (https://www.ncqa.org/wp-content/uploads/2018/08/20171017_PCMH_Evidence_Report.pdf) presents evidence for the value of patient centered medical homes "that PCMHs are saving money ..., and improving patient outcomes." The Rhode Island Medical home Portal https://ri.medicalhomeportal.org/ is a unique source of reliable information about children and youth with special healthcare needs(CYSHCN) offering a “one stop shop” for families, physicians and the medical home team, care coordinators and community partners. Once on the site, a visitor can research diagnoses, find linkages to Rhode Island pediatric specialists, design a custom care notebook, and create a Rhode Island Service Provider list that automatically updates when there is a change in the listing. This information is available 24/7 and is beneficial to both families and providers. If a visitor would rather speak to someone, the help page will direct the visitor to the RIPIN Call Center. Patient centered medical homes can trust the MHP to provide timely resources and materials while the patient is still in the office

Data Sources and Data Issues: RIDOH CSHCN Program

Year: 2020

Unit Type: Simple Count, Unit Number: 30,000