Skip Navigation

Strengthening the evidence for maternal and child health programs

Find State ESMs


Displaying records 1 through 8 (8 total).

ESM 12.1 Percent of youth ages 14 and older receiving services from the DPH Care Coordination Program who receive health transition information and support from their Care Coordinator (Massachusetts)

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-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: All families of youth with special health care needs (YSHCN) ages 14 and older who receive services from the DPH Care Coordination Program will receive the education and support necessary to assist and prepare their youth for successful health transi

Numerator: Number of YSHCN ages 14 and older who received services from the DPH Care Coordination Program that received health transition information and support

Denominator: Number of YSHCN ages 14 and older who received services from the DPH Care Coordination Program

Significance: As stated in the Clinical Report, Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home, jointly authored by the American Academy of Pediatrics, American Academy of Family Physicians and American College of Physicians, care coordination is part of transition planning for CYSHCN and may be instrumental in supporting the transfer of care from pediatric to adult medical subspecialists. Got Transition’s Six Core Elements cites care coordinators as key members of the collaborative team to support health care transition to adulthood. By providing information and support, DPH Care Coordinators can assist and complement the medical home’s work on transition readiness.

Data Sources and Data Issues: Data will be accessed from the DPH Care Coordination database. Care Coordinators track service delivery and record in the database the types of services provided to each client who received CC services during the reporting period. The database will need to be modified to include a data element on provision of health transition information and support. Systems will need to be put in place to flag youth who should receive these services.

Year: 2020

Unit Type: Percentage, Unit Number: 100

ESM 12.1 Percent of young adults with special health care needs, ages 18-21, who identify an adult health care provider at discharge from the Title V program (New Hampshire)

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 increase the percent of adolescents with special health care needs, ages 14 – 20, who received services necessary to make transitions to adult health care

Numerator: the number of adolescents or family caregivers in the denominator who indicated their goal had been achieved, when reviewed at one year

Denominator: number of adolescents with special health care needs, ages 14 – 20, who identified a goal related to transition during TRAQ consultation with their health care coordinator

Significance: Effective transition from pediatric to adult health care promotes continuity of developmental and age-appropriate care for youth with special health care needs. Yet years of national, state and community studies continue to demonstrate that most youth with special health care needs (SHCN) and families do not receive the support they need in the transition from pediatric to adult health care. Improvements are needed to raise awareness of youth and their families that maintaining health and continuity of care are important to attaining broader adult goals. (Pediatrics November 2018, 142 (5) e20182587; DOI: https://doi.org/10.1542/peds.2018-2587)

Data Sources and Data Issues: BFCS will use the SMS database to collect data. Currently, the system allows for the health care coordinator to record transition enSimple Counters as “TRAQ sent” and/or “TRAQ completed”. A system update will be required to add options to record “Transition goal identified” and “Transition goal met”. Instructions will be provided to health care coordinators to require an enSimple Counter note be included in the documentation that identifies the goal.

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 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 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 12.3 Percent of transition age CSHCN (ages 12 through 17) served by Title V CSHCN who received transition services and supports in the past 12 months from Title V CSHCN (Arkansas)

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: To empower families of CSHCN by educating them on all levels of transition and how to obtain needed information from providers

Numerator: Unduplicated number of transition age youth (ages 12 through 17) served by Title V CSHCN who received transition services and supports from Title V CSHCN in the past 12 months

Denominator: Unduplicated number of transition age youth (ages 12 through 17) served by Title V CSHCN

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 American Academy of Pediatrics, the American Academy of Family Physicians, and the 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: Therapy unduplicated transition age youth reports, Title V CSHCN staff monthly activity reports and Title V CSHCN Health Care Transition Quality Improvement audits

Year: 2020

Unit Type: Percentage, Unit Number: 100

ESM 12.3 Decrease percent of families of transition-age youth who have not prepared for medical 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: 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: Decrease percent of families of transition-age youth who have not prepared for medical transition to adulthood.

Numerator: Number of families of transition-aged youth with special health care needs (12 years+) surveyed who indicated they have not prepared for transition to adult health care.

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. In the 2019 CYSHCN Outreach Survey, a quarter of respondents (25.1%) felt prepared for their child to transition to adult medical care. Furthermore, 98 of 214 respondents with transition-aged youth (45.8%) indicated they have not prepared for medical needs as an adult. 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. Family education, outreach, and support will lead to increased planning for transition to adult health care.

Data Sources and Data Issues: Data Source: CYSHCN Outreach Survey Responses to the CYSHCN Outreach Survey will be collected on an biennial basis. The survey will be 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. According to the 2019 CYSHCN Outreach Survey as part of the 2020 Title V Five Year Needs Assessment, 98 of 214 respondents with transition-aged youth (45.8%) indicated they have not prepared for medical needs as an adult. 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.

Year: 2020

Unit Type: Percentage, Unit Number: 100

   

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.