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Strengthening the evidence for maternal and child health programs

Find State ESMs


Displaying records 21 through 40 (60 total).

ESM 12.1 Percent of health transition training participants who reported a change in knowledge, practice, or policy (Nevada)

Measure Status: Active

Evidence Level: Emerging. Aligns with MCHbest strategy "Provider Training/Workforce Development" (https://www.mchevidence.org/tools/strategies/12-1.php). Find other NPM 12 provider-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: Increase the percent of transition training participants with a change in knowledge, practice, or policy

Numerator: Number of transition training participants who reported a change in knowledge, practice, or policy

Denominator: Number of transition training participants

Significance: The transition of youth to adulthood, including the movement from a child to an adult model of healthcare, has become a statewide priority issue based on the 2020 Needs Assessment. Poor health has the potential to impact negatively the youth and young adults’ academic and vocational outcomes. Over 90 percent of children with special health care needs now live to adulthood, but are less likely than their non-disabled peers to complete high school, attend college or to be employed. Health and health care are cited as two of the major barriers to making successful transitions.

Data Sources and Data Issues: Title V MCH Program. The results of the pre- and post-test surveys administered to Health Care Transition training participants.

Year: 2020

Unit Type: Percentage, Unit Number: 100

ESM 12.1 Percent of families of transition age youth with special health care needs receiving professional help with their child’s transition to adulthood (Texas)

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: Assess the provision of transition services to evaluate provider education, outreach and promotion of best practices, and to inform efforts to support providers and families.

Numerator: Number of families of transition-aged youth with special health care needs (12 years+) surveyed who indicated they received professional help with transition services

Denominator: Total number of families of transition-aged youth with special health care needs (12 years+) surveyed

Significance: The AAP outlined guidelines to promote successful transition from pediatric to adult health care in a 2011 Clinical Report. The Got Transition Six Core Elements operationalized the components of health care transition support by establishing evidence-based tools for use by providers and families. According to the 2017-2018 NSCH, 87.0% percent of the Texas CSHCN population did not receive the services necessary to transition to adult health care compared to 81.1 percent of CSHCN in the United States. In the Title V CSHCN Parental Outreach Survey, 75% of respondents said that they did not feel prepared for their child’s transition. Only 7.0% of respondents prepared for transition in at least four out of seven transition areas with a professional. Most respondents who indicated that they had prepared for their child’s transition had done so by themselves. The percent of families of transition-age youth who indicate they received professional help with transition services for their child is derived from the CYSHCN Outreach Survey. Data collected reflects the number of survey respondents who indicate that a professional helped them with four or more of the following areas of transition needs: medical, educational, independent living, financial, social, employment, and legal. Successful provider education, outreach, and promotion of best practices, including Got Transition’s Six Core Elements, will lead to increased knowledge, attitudes, and implementation skills for providing transition support. Successful family education, outreach, and support will lead to increased demand for quality transition services.

Data Sources and Data Issues: Data Source: CYSHCN Outreach Survey Responses to the CYSHCN Outreach Survey will be collected on a biennial basis. The survey will be mailed out and dispersed electronically to families served by HHSC CSHCN health care benefits and MCHS contractors in both English and Spanish formats. The survey will be promoted through email communication, newsletters, and webpages. According to the 2019 CYSHCN Outreach Survey as part of the 2020 Title V Five Year Needs Assessment, 15 of 214 respondents with transition-aged youth (7.0%) indicated they received professional help with four or more of the seven areas of transition 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 areas of need for additional ongoing needs assessment activities including focus groups and interviews.

Year: 2020

Unit Type: Percentage, Unit Number: 100

ESM 12.1 Percent of CYSHCN ages 12-17 years served by Special Child Health Services Case Management Units (SCHS CMUs) with at least one transition to adulthood service (New Jersey)

Measure Status: Active

Evidence Level: Moderate. Aligns with MCHbest strategy "Transition Care Coordination Services" (https://www.mchevidence.org/tools/strategies/12-4.php). 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: 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: ESM 12.1 monitors over 20 services, within 7 categories: PCP; transition-specific services; employment; health insurance; Supplemental Security Income; Shared Plan of Care; and any service tied to ‘transition to adulthood’ as an exceptional event.

Numerator: Number of CYSHCN ages 12-17 years served by SCHS CMUs with at least one transition to adulthood service

Denominator: Number of CYSHCN ages 12-17 years served by SCHS CMUs

Significance: The transition of youth to adulthood has become a priority issue nationwide as evidenced by the clinical report and algorithm developed jointly by the AAP, American Academy of Family Physicians and American College of Physicians to improve healthcare transitions for all youth and families. Over 90% of children with special health care needs now live to adulthood, but are less likely than their non-disabled peers to complete high school, attend college or to be employed. Successful transition to all aspects of adulthood is a critical life course measure for CYSHCN.

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

ESM 12.1 Percent of CSHCS clients age 18 to 21 years in selected diagnosis groups that have transferred care from a pediatric to an adult provider (Michigan)

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: 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: To monitor and increase the number of young adults that appropriately transfer care from a pediatric to an adult health care provider.

Numerator: The number of CSHCS enrollees, aged 18 to 21, that have transferred care from a pediatric to an adult provider.

Denominator: The total number of CSHCS enrollees, aged 18 to 21, that have received care from a pediatric provider.

Significance: This measure is significant as it allows us to evaluate the percentage of adolescents and young adults with special needs that are transferring care from a pediatric to an adult provider. By analyzing the providers these young adults are seeing (CSHCS authorized providers and Medicaid Claims), we can determine if new providers have been identified, and if the initial visit with the adult provider was completed.

Data Sources and Data Issues: This ESM combines three separate data sources: 1) the CSHCS database, 2) the CHAMPS (Medicaid Claims) database, and 3) a University of Michigan provider database. These three databases provide information on CSHCS clients, and the providers they see.

Year: 2020

Unit Type: Percentage, Unit Number: 100

ESM 12.1 Percent of CSHCN ages 12-17 enrolled in Children with Medical Handicaps with a transition plan in place (Ohio)

Measure Status: Active

Evidence Level: Moderate. Aligns with MCHbest strategy "Transition Care Coordination Services" (https://www.mchevidence.org/tools/strategies/12-4.php). Find other NPM 12 practice/patient-level strategies 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: Increase the percent of CSHCN ages 12-17 enrolled in the Children with Medical Handicaps program who have a transition plan in place

Numerator: Number of adolescents ages 12-17 enrolled in the Children with Medical Handicaps program who have a transition plan in place

Denominator: Number of adolescents ages 12-17 enrolled in the Children with Medical Handicaps program

Significance: CSHCN enrolled in CMH have complex medical needs that require coordination of numerous actors to ensure adequate management. To ensure this population is prepared to transition to adult health care and participate fully in this process, a transition plan is necessary. By tracking progress in increasing the proportion of CSHCN in CMH with a transition plan in place, we can measure our efforts to increase the percent of adolescents with and without special health care needs who received services necessary to make transitions to adult health care, among the most medically complex CSHCN.

Data Sources and Data Issues: Data will be pulled from the system used by the Children with Medical Handicaps program, CMACS.

Year: 2020

Unit Type: Percentage, Unit Number: 100

ESM 12.1 % of CYSHN that have had a transition planning meeting by their 18th birthday (Vermont)

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 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: Achieve a comprehensive, coordinated, and integrated state and community system of services for children.

Numerator: Number of CSHCN who receive transition meetings before their 18th birthday.

Denominator: Number of CSHCN turning 18

Significance: It is important for all youth to be connected to programs, services, activities, and supports that prepare them to manage their physical, mental and emotional well-being and develop life skills to make informed choices. The ability to manage one's health is a critical factor in success in school and transitioning into employment. This is especially true for youth with life-long health conditions. By assuring that youth working with the state CSHN program receive a transition meeting prior to their 18th birthday, we can better ensure youth are on the path to experience a positive transition.

Data Sources and Data Issues: Data source: Program data

Year: 2020

Unit Type: Percentage, Unit Number: 100

ESM 12.1 Number of transition resources identified (Tennessee)

Measure Status: Active

Evidence Level: Emerging. Aligns with MCHbest strategy "Training/Educating Youth" (https://www.mchevidence.org/tools/strategies/12-3.php). Find other NPM 12 patient-level strategies in MCHbest.

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

Service Type: Enabling services level of pyramid

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

Service Recipient: Activities directed to families/children/youth

Goal: To increase the number of youth with special health care needs that receive services necessary for successful transition.

Numerator: Number of transition resources identified

Denominator: n/a

Significance: Families and youth need to be aware of the importance of a transition plan. The data repository will be developed in a manner that it will collect the type and number of resources identified.

Data Sources and Data Issues: CYSHCN MCH/Title V Program data

Year: 2020

Unit Type: Simple Count, Unit Number: 65

ESM 12.1 Number of providers in Virginia who have completed the transition training module. (Virginia)

Measure Status: Active

Evidence Level: Emerging. Aligns with MCHbest strategy "Professional Training/Workforce Development" (https://www.mchevidence.org/tools/strategies/12-1.php). Find other NPM 12 provider-level strategies in MCHbest.

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 number of children ages 10-24 engaged in transition services to adult health care

Numerator: Number of providers in Virginia who have completed the transition training module

Denominator: n/a

Significance: This ESM was identified through the Title V needs assessment, Virginia's Well-being Plan, and Healthy People 2020 (DH-5).

Data Sources and Data Issues: Virginia Department of Health, Office of Family Health Services, Division of Child and Family Health

Year: 2020

Unit Type: Simple Count, Unit Number: 100,000

ESM 12.1 Number of participants in Center for Youth and Adults with Conditions of Childhood (CYACC) clinical services. (Indiana)

Measure Status: Active

Evidence Level: This ESM is based on state data and 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 1: Measuring quantity of effort (counts and "yes/no" activities)

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 adolescents with and without special health care needs who have received the services necessary to make transitions to all aspects of adult life, including adult health care, work, and independence.

Numerator: Unduplicated cumulative number of participants

Denominator: Absolute number of participants

Significance: The transition of youth to adulthood has become a priority issue nationwide as evidenced by the clinical report and algorithm developed jointly by the AAP, American Academy of Family Physicians and American College of Physicians to improve healthcare transitions for all youth and families. Over 90 percent of children with special health care needs now live to adulthood, but are less likely than their non-disabled peers to complete high school, attend college or to be employed. Health and health care are cited as two of the major barriers to making successful transitions.

Data Sources and Data Issues: Center for Youth and Adults with Conditions of Childhood (CYACC)

Year: 2020

Unit Type: Simple Count, Unit Number: 1,000

ESM 12.1 Number of families/providers who obtain needed support from Neni 311 for a support service. [Note: this ESM actually reports a percent, even though the title indicates a number count.] (Guam)

Measure Status: Active

Evidence Level: Moderate. Aligns with MCHbest strategy "Transition Care Coordination Services" (https://www.mchevidence.org/tools/strategies/12-4.php). Find other NPM 12 family-level strategies in MCHbest.

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 directed to families/children/youth

Goal: Increasing utilization of a medical home by increasing access to resources for providers and/or families of CSCHN or non-CSCHN .

Numerator: Number of families/providers who obtain needed support.

Denominator: Number of families/providers who contact Neni 311.

Significance: Neni 311 is a free help line and community network that connects parents and providers with culturally appropriate resources, health care coordination, services and information to maximize healthy growth and development of children and families. Neni 311 is modeled after Help Me Grow which is an evidence-based system that connects at-risk children with the services they need. Help Me Grow builds collaboration across sectors and improve access by identifying gaps and barriers to access.

Data Sources and Data Issues: Neni 311 log book or database

Year: 2020

Unit Type: Percentage, Unit Number: 100

ESM 12.1 Number of families who received support or services from the Family to Family Resource Center (Idaho)

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+support&NPM=12&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/12-transition.php).

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

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, increase the number of families who receive support or services focused on improving transition to adulthood for CSHCN.

Numerator: Number of families who received support or services from the Family-to-Family Resource Center

Denominator: N/A

Significance: Families of CSHCN face complex challenges, many of which only another family with similar challenges may understand. Family-to-Family Information Centers, Health Resources and Services Administration (HRSA) funded facilities, are a vital resource for families, and provide assistance with finding appropriate care, referrals to providers, and a range of other services (Family Voices, 2020). IPUL is a statewide organization committed to educating, empowering, supporting and advocating for individuals with disabilities and their families (IPUL, n.d.d). IPUL houses Idaho’s Family-to-Family Health Information Center and helps to facilitate informed choices for families concerning health care while providing training, information, and resources to approximately 5,000 families and professionals each year (IPUL, n.d.b). IPUL offers services at no cost to families (IPUL, n.d.b). Family engagement plays a crucial role in successfully delivering health care services. Family participation engages families in the planning development, and evaluation of programs and policies at the community, organizational and policy levels (Association of Maternal and Child Health Programs [AMCHP], 2010). Multiple studies indicate that both family and patient engagement enhance patient health outcomes (Agency for Healthcare Research and Quality, 2017; Carman, 2013; Gunther, 2013; Ingoldsby, 2010; O’Sullivan, 2014). Research shows a successful first step to increasing family engagement is to improve the methods of recruitment and retention of parents and families in both MCH and CSHCN programs (AMCHP, 2016b). According to AMCHP, the most successful programs are those that require involvement from parents and families, regularly teach and train their staff about the importance of family engagement, and provide guidance for family and staff on effective methods of enhancing family engagement (AMCHP, (2016a); AMCHP, 2016b; Family Voices, 2008).

Data Sources and Data Issues: Family-to-Family Resource Center (IPUL)

Year: 2020

Unit Type: Simple Count, Unit Number: 10

ESM 12.1 Number of families that received a resource from the CYSHCN program. (Arizona)

Measure Status: Active

Evidence Level: Moderate. Aligns with MCHbest strategy 12.4 "Transition Care Coordination Services" (https://www.mchevidence.org/tools/strategies/12-4.php). Find other NPM 12 patient/family/practice-level strategies in MCHbest.

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: By 2020, 2000 families will receive resources (information and referrals) to support them in navigating systems of care.

Numerator: Number of families

Denominator: None

Significance: The Children and Youth with Special Healthcare Needs Program offer vital information and support for families to help navigate a complex system of care. This metric was designed to help the program monitor its population reach.

Data Sources and Data Issues: CYSHCN program

Year: 2020

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

ESM 12.1 Number of families of 15 - 17 year olds with special health care needs who attend the Supported Decision-Making class (Maine)

Measure Status: Active

Evidence Level: Emerging. Aligns with MCHbest strategy "Training/Educating Youth" (https://www.mchevidence.org/tools/strategies/12-3.php). Find other NPM 12 patient/family-level strategies in MCHbest.

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 of 15 - 17 year olds with special health care needs who attend the Supported Decision-Making class.

Numerator: Number of families of 15 - 17 year olds with special health care needs who attended class during the FFY

Denominator: N/A

Significance: A key component of a successful transition to adult health services is primary care providers working with youth to gain needed skills and understand changes that will occur in their health care. Supported decision making is an alternative to full guardianship that promotes self-determination, while providing help with decision making in a trusted and formalized environment. Supported decision making can provide increased opportunities for independence and autonomy as a person's needs change. Tracking the number of families who attend the Maine Parent Federation's Supported Decision Making class will allow the Maine Children with Special Health Needs Program to determine whether efforts to encourage primary care providers to refer families to the class have been successful.

Data Sources and Data Issues: Maine Parent Federation class roster

Year: 2020

Unit Type: Simple Count, Unit Number: 1,000

ESM 12.1 Number of CSHCN provided with transition services (District of Columbia)

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 3: Measuring quantity 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: Provide transition planning services to youth and teens with special health care needs and their families between the ages of 14-21.

Numerator: Number of CSHCN provided with transition services

Denominator: N/A

Significance: According to latest data from the 2009/2010 National Survey of Children with Speical Health Care Needs 16.6% of children (18,819 in 2009/2010) living in the District have special health care needs (compared to 15.1% nationally). A total of 33.8% of youth with special health care needs receive the services necessary to make transitions to adult health care compared to 40% nationally.

Data Sources and Data Issues: Children’s National Parent Navigator Program

Year: 2020

Unit Type: Simple Count, Unit Number: 100,000

ESM 12.1 Health Care Transition Services (Maryland)

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 3: Measuring quantity 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 the number of YSHCN and their families who participating in transition planning activities for their YSHCN

Numerator: Number of YSHCN and families that participate in transition planning activities.

Denominator: N/A

Significance: According to American Academy of Pediatrics, Supporting the health care transition from adolescence to adulthood in the medical home, as teens grow into adulthood, their health care needs change. During this transition, most teens may begin to take more responsibility for their health care and most will need to leave their pediatricians for adult health care providers. As teens with special health care needs become adults, receiving proper health care can be a challenge. Youth participating in their Health Care Transition Planning is part of the process of becoming independent and learning to manage one’s own health while preventing periods of gaps in services. Losing access to primary care, even for a short time, can affect the long-term health of a youth with special health care needs.

Data Sources and Data Issues: DHMH/MCHB Data

Year: 2020

Unit Type: Simple Count, Unit Number: 50,000

ESM 12.1 Employ Health Care Transitions (HCT) Process Measurement tool towards assessing progress on implementation of Six Core Elements of Health Care Transitions statewide (Kentucky)

Measure Status: Active

Evidence Level: Moderate. Aligns with MCHbest strategy "Six Core Elements Adaptation with Quality Improvement (QI)" (https://www.mchevidence.org/tools/strategies/12-6.php). Find other NPM 12 practice-level strategies in MCHbest.

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: 5. Create/champion/implement policy

Service Recipient: Activities related to systems-building

Goal: Measure the implementation of agency-wide improvements as guided by Health Care Transition Process Measurement Tool for Transitioning Youth to Adult Health Care Providers

Numerator: Score on HCT tool, as assessed annually

Denominator: Possible Score on HCT tool

Significance: Statewide HCT improvements shall be guided by research-based instrument conforming to consensus statement of best practice and CYSHCN national standards.

Data Sources and Data Issues: Health Care Transition Process Measurement Tool for Transitioning Youth to Adult Health Care Providers, created by Got Transitions, and scored for Kentucky by OCSHCN.

Year: 2020

Unit Type: Percentage, Unit Number: 100

ESM 12.1 Degree to which the Title V Children and Youth with Special Health Needs Section promotes and/or facilitates transition to adult health care for Youth with Special Health Care Needs (YSHCN), related to Six Core Elements of Health Care Transition 2.0. (Hawaii)

Measure Status: Active

Evidence Level: Moderate. Aligns with MCHbest strategy 12.6 "Six Core Elements Adaptation with Quality Improvement (QI)" (https://www.mchevidence.org/tools/strategies/12-6.php). Find other NPM 12 practice-level strategies in MCHbest.

Measurement Quadrant: Quadrant 3: Measuring quantity 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: To increase the degree to which the Title V CYSHNS promotes and/or facilitates transition to adult health care for YSHCN.

Numerator: Total Actual Score from Transition to Adult Health Care Data Collection Form

Denominator: Total Possible Score from Transition to Adult Health Care Data Collection Form (33)

Significance: CYSHNS is addressing Got Transition’s Six Core Elements of Health Care Transition 2.0. Strategy components were adapted for integration as part of CYSHNS services to support youth/families in preparing for transition to adult health care. Health and health care are important to making successful transitions. The majority of YSHCN do not receive needed support to transition from pediatric to adult health care. In addition, YSHCN, compared to those without special health care needs, are less likely to complete high school, attend college, or be employed. The Title V CYSHNS has been addressing these barriers through providing general transition information to families receiving CYSHNS /clinic services or attending transition-related community events, and leading/participating in planning Transition Fairs. The next phase is CYSHNS working to improve its direct services with youth/families related to transition to adult health care, using an evidence-informed quality improvement approach. The Six Core Elements of Health Care Transition is an evidence-informed model for transitioning youth to adult health care providers that has been developed and tested in various clinical and health plan settings. They were developed by the Got Transition/Center for Health Care Transition Improvement, based on the joint clinical recommendations from the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), and American College of Physicians (ACP). References: Got Transition, “Side-By-Side Version, Six Core Elements of Health Care Transition 2.0”; AAP, AAFP, ACP, “Clinical Report – Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home”, Pediatrics 2011;128:182-200; McPheeters M et al., “Transition Care for Children With Special Health Needs”, Technical Brief No. 15. Agency for Healthcare Research and Quality (AHRQ) Publication No. 14-EHC027-EF, June 2014.

Data Sources and Data Issues: This is a summary of the Data Collection Form that lists 11 strategy components organized by the Six Core Elements of Health Care Transition: • Transition policy • Transition tracking and monitoring • Transition readiness • Transition planning • Transfer of care • Transition completion. Each item is scored from 0-3 (0=not met; 1=partially met; 2=mostly met; 3=completely met), with a maximum total of 33. Scoring is completed by CSHNP staff, with input from Hilopaa Family to Family Health Information Center. The data collection form is attached as a supporting document.

Year: 2020

Unit Type: Scale, Unit Number: 33

ESM 12.2 Percentage of Virginia schools reporting into the VDOE school health data system (Virginia)

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=school+system&NPM=12&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/12-transition.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: 1. Assess and monitor population health

Service Recipient: Activities related to systems-building

Goal: Maintain and expand MCH data capacity regarding school health

Numerator: Number of Virginia schools reporting into the VDOE school health data system

Denominator: Number of Virginia schools

Significance: School nurses recognize the importance of each student having a medical home and healthcare transition services, as supported by the American Academy of Pediatrics, American Academy of Family Physicians and American College of Physicians. Poor health has the potential to impact negatively the youth and young adults’ academic and vocational outcomes. Health and health care are cited as two of the major barriers to making successful transitions. The VDH School Health Nurse Consultant partnership with the VDOE School Nurse Consultant is critical to understanding scope of needs and services regarding school health in Virginia.

Data Sources and Data Issues: VDH and VDOE School Health Nurse Documentation (numerator); VDOE Statistics and Reports, Enrollment & Demographic tables, Local and Regional Schools and Centers (denominator) (http://www.doe.virginia.gov/statistics_reports/enrollment/index.shtml)

Year: 2020

Unit Type: Percentage, Unit Number: 100

ESM 12.2 Percent of YSHCN enrolled in State CSHCN program who report satisfaction with their transition experience to adulthood. (Alabama)

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=satisfaction&NPM=12&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/12-transition.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: To improve the transition experience.

Numerator: Number of youth that indicate satisfaction regarding their transition experience.

Denominator: Total number of youth surveyed.

Significance: The Standards for Systems of Care for Children and Youth with Special Health Care Needs Version 2.0 System Domain Transition to Adulthood indicates the system should contact the young adult/caregiver confirming transfer of care and eliciting feedback on experience with the transition process. Ensuring the successful transition of youth and young adults with special health care needs is essential to individual self-determination and self-management. Young Adult/Caregiver perception of satisfaction with their transition to adult health care will help determine quality improvement measures to drive program development that supports the achievement of successful outcomes.

Data Sources and Data Issues: Survey based on the Six Core Elements of Health Care Transition 2.0 Health Care Transition Feedback Survey for Youth. A potential issue when collecting data using a survey format is a limited number of respondents which could impact the outcome.

Year: 2020

Unit Type: Percentage, Unit Number: 100

ESM 12.2 Percent of participants trained on youth health care transition concepts who report a change in knowledge, skills, or intended behavior following the training (Wisconsin)

Measure Status: Active

Evidence Level: Emerging. Aligns with MCHbest strategy "Training/Educating Youth" (https://www.mchevidence.org/tools/strategies/12-3.php). Find other NPM 12 patient-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: 8. Build and support a workforce

Service Recipient: Activities directed to families/children/youth

Goal: 600 participants will be trained, and 80% of those completing an evaluation following their training will report a change in knowledge, skills, or intended behavior.

Numerator: Number of participants trained on youth health care transition concepts who report a change in knowledge, skills, or intended behavior following the training

Denominator: Number of participants trained on youth health care transition concepts, who complete an evaluation following their training

Significance: Trainings will increase the knowledge and skills about transition among families, health care providers, and other community health professionals, and evaluations following the training will assure the effectiveness of the trainings.

Data Sources and Data Issues: REDCap. No data concerns anticipated.

Year: 2020

Unit Type: Percentage, Unit Number: 100

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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.