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Title V Technical Assistance Meeting

 Putting Evidence into Practice - Advancing National Performance Measure 11 in States

Putting Evidence into Practice: Advancing National Performance Measure 11 in States

Prepared by the National Center for Medical Home Implementation, a cooperative agreement between the American Academy of Pediatrics and the Maternal and Child Health Bureau of the U.S. Health Resources and Services Administration.

Title V programs have been tasked with operationalizing evidence-based/informed strategies. To assist with implementation of concrete activities and initiatives, the 47 states and jurisdictions that selected Measure 11 (NPM 11) — medical home — can utilize ideas from and engage in peer learning with other state and local agencies.

Strategies and implementation insights exist to help support peer learning and collaboration in Title V programs to achieve progress on NPM 11. Some of these activities are facilitated through state chapters of the American Academy of Pediatrics or Medicaid agencies, providing ample opportunity for Title V programs to leverage existing medical home initiatives. In addition, the National Center for Medical Home Implementation (NCMHI) provides tools, resources and technical assistance to support Title V programs in these efforts.

Strategy: Engage Families in Pediatric Medical Home Implementation

Implementation Insights:

  • Support employment of family members in pediatric practices as peer navigators.

The Rhode Island Pediatric Practice Enhancement Project employs caregivers of children and youth with special health care needs within pediatric practices to enhance care coordination services for families. The program is primarily funded through the Title V Maternal and Child Health Block Grant.

  • Encourage inclusion of parent/caregiver partners as core team members in quality improvement efforts.

The Pennsylvania Medical Home Initiative has trained more than 150 diverse pediatric and adult practice teams in medical home principles. Participating practices are required to pair with and engage parent partners in specific quality improvement and practice transformation activities. 

Strategy: Partner and Collaborate with Diverse Stakeholders

Implementation Insights:

  • Collaborate with public and private organizations, including state chapters of the American Academy of Pediatrics and Family-to-Family Health Information Centers.

New Jersey's Medical Home Collaboratives are facilitated through a partnership between the state Family-to-Family Health Information Center, Title V program, and state chapter of the American Academy of Pediatrics.

  • Develop standardized documentation and formal written agreements across partnering agencies.

The North Carolina chapter of the American Academy of Pediatrics partnered with the state's Medicaid agency, Division of Social Services, and County Departments of Social Services to facilitate the Fostering Health North Carolina program. The program develops standardized documentation and formal written agreements across agencies that care for children and youth in foster care to ensure access to a pediatric medical home.

Strategy: Implement and Support Quality Improvement Initiatives 

Implementation Insights:

  • Recruit and train pediatric practice staff in quality improvement science.

The Massachusetts Children's Health Insurance Program Reauthorization Act Quality Demonstration Grant utilized Practice Transformation Facilitators (PTFs) to encourage quality improvement for medical home transformation in pediatric practices. The PTFs were co-located and employed by each participating clinic and underwent special training in quality improvement methodology.

  • Offer incentives to practices for participation in quality improvement initiatives.

The Illinois Chapter of the American Academy of Pediatrics collaborated with multiple partners, including the state's Title V Children and Youth with Special Health Care Needs program, to facilitate a quality improvement initiative focused on medical home transformation in 10 pediatric practices across the state. Participating clinicians were offered Maintenance of Certification Part 4 points and Continuing Medical Education credit.

Strategy: Support the Utilization of a Shared Plan of Care

Implementation Insights:

  • Create a shared plan of care template.

The Child Health Improvement Program in Vermont is creating a shared plan of care template which will consolidate health data as well as information on economic, environmental, and social determinants of health for children and youth with special health care needs. After its creation, the electronic shared plan of care can be accessed by families and clinicians to improve care coordination and system integration.

  • Provide a common platform to house a shared plan of care across multiple agencies.

The Connecticut Department of Health care coordination portal houses shared plans of care for children and youth with special health care needs. These plans are accessed and used by Title V-funded care coordinators to enhance care for patients and families.

Resources and Tools for Title V Programs

Want to learn more about state medical home implementation initiatives aligned with National Performance Measure 11? View the following National Center for Medical Home Implementation resources: