Title V Transformation Tools
Recommendations to Support NPM 11 – Medical Home
Jump To: Skills | Knowledge
Significance. The Title V Maternal and Child Health Services Block Grant to States Program guidance1 defines the significance of this NPM 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."
Background. The Maternal and Child Health Bureau (MCHB) Title V Maternal and Child Health Services Block Grants to States Program has established 15 National Performance Measures (NPMs) for the 2015-2017 grant cycle. In order to effectively address the NPMs, MCH professionals need to think about not only the evidence and strategies to make change, but also the capacity of the workforce to carry out these activities. These lists identify online learning materials, resources, and evidence-based strategies and programs to support the knowledge sets and skills needed to advance each NPM.
Introduction. Six skill sets have been identified by the National MCH Workforce Development Center to support implementation of the Title V National Performance Measure (NPM) 5: Safe Sleep: (1) population health; (2) strategic planning and program design; (3) strategic alliances and effective partnerships; (4) consumer engagement and cultural and linguistic brokering; (5) policy and program implementation; and (6) communication.
In addition, two knowledge areas specific to the NPM topic area have been highlighted that are keyed to the evidence base and promising practices: (1) medical home background, recommendations, and guidelines and (2) medical home policies and strategies.
The MCH Navigator, in collaboration with the Center, has developed this crosswalk to guide MCH professionals to online learning opportunities and implementation resources to support these skill sets.
Please click on the Read More buttons below for additional information, learning materials, and implementation resources. You can also email us with suggestions for additions.
Six skill sets have been identified to support implementation of this NPM:
1. Population Health
A renewed focus on MCH population health is key to achieving the NPMs in the era of health transformation. These skills enable Title V professionals to analyze how program interventions and their related health outcomes are distributed among a state’s MCH population. Population health skills complement all of Title V’s work, including program design and implementation, strategic partnerships and communication.
- Skills to effectively use data systems for service delivery improvements and reporting
- Ability to assess and report the quality of medical homes within the state or territory
2. Strategic Planning & Program Design
Effective strategic planning and program design require the ability to base programs on defined goals and desired outcomes. Strategic planning should include a monitoring and evaluation system to track and monitor progress and inform program alterations as needed. Program design skills must ultimately be coupled with implementation, where program design is carried out.
- Ability to conduct strengths-opportunities-weaknesses-threat analyses to determine how best to support medical home efforts for children within the state or territory
- Ability to assess where practices currently fall on the medical home implementation continuum
3. Strategic Alliances & Effective Partnerships
The wide array of stakeholders and partners in the field of MCH, from providers and insurers to women and children, require a set of skills in strategically aligning Title V goals with those of their partners. In the Title V world, there is an increasing interest in engaging unlikely or nontraditional partners to achieve the NPMs. The skills in this category take that into account and include unique partner groups linked to this measure.
- Ability to convene stakeholders to:
- Ensure knowledge of, visualize and analyze current medical homes in local communities
- Advance medical home service utilization
- Identify, understand, and remove barriers to receiving care in medical homes
- Support the establishment of new medical homes as appropriate
- Build and Maintain a coordinated system from the state/territory level
4. Consumer Engagement/Cultural & Linguistic Brokering
Consumers are arguably the most important stakeholders in MCH work, thus skills in consumer engagement and cultural and linguistic brokering are essential to moving the needle for each NPM. In some cases, consumer engagement includes negotiating with other stakeholders on behalf of MCH populations. Closely linked with this skills category are skills in communication and strategic alliances.
- Skills to promote patient- and family-centered care that ensures shared decision making for families who use medical homes
- Ability to assess cultural competence of services received by families who use medical homes
- Skills to support an official role for underserved families in larger stakeholder medical home efforts
5. Policy & Program Implementation
These skills ensure that MCH priorities are integrated into all aspects of policy and program implementation, as well as ensuring that policies and programs selected are well-aligned with NPMs and other MCH program goals. Implementing policies and programs with fidelity also requires skills in the implementation science drivers: technical and adaptive leadership; selection; training; coaching; systems intervention; facilitative administration; and decision support data systems.
- Skills in quality improvement to:
- Help guide medical home practices on workflow, ensuring quality health care delivery
- Ensure high quality services in medical homes for which Title V has authority
- Ability to assist in the development of comprehensive care plans/care planning in medical homes that are driven by families and shared across systems
- Ability to adapt standards for pediatric practices, such as the National Committee for Quality Assurance, in medical homes
- Ability to implement or support telemedicine clinics as part of medical home model
- Ability to determine legal authority behind existing memoranda of understanding with governmental agencies about medical homes
- Skills to develop memoranda of understanding with Medicaid and other payers that includes language providing for payment reforms that support medical homes and care integration models
- Ability to ensure that Title V-sponsored care coordinators are trained to make and ensure completion of referrals to medical homes
- Ability to include measurements of family perspectives in program evaluation plans
- Ability to ensure that medical homes can meet the needs of both typically developing children and those with special health care needs
Communication skills support the creation and delivery of effective messages between MCH professionals, professional and community partners, and populations served by Title V. Effective communication ensures the delivery of appropriate messages to audiences in the way that they were intended and is key to all aspects of MCH work. These skills are linked closely with skills in strategic partnerships and cultural and linguistic brokering.
- Ability to communicate effectively with providers, families, and community stakeholders to align systems and ensure medical homes serve all children who need them
- Ability to use traditional and/or social media marketing/outreach to communicate effectively with the public about the importance of medical homes for children and families
In addition to skills, each NPM requires a knowledge base that will help Title V progress effectively in the measure. Knowledge should be considered at the foundation of achieving all measures.
1. Medical Home Background, Recommendations & Guidelines
- Knowledge of medical home language and definitions, especially pediatric medical homes
- Knowledge of best practices models of pediatric medical home
- Knowledge and appreciation of differing definitions of population health (and population health management) across sectors, including public health, hospital systems, accountable care organizations (ACOs), and medical providers
- Knowledge of medical home standards (including the National Committee on Quality Assurance pediatrics standards for medical homes) and quality indicators, including evidence-based care practices
- Knowledge about state and local medical home registries and current gaps in medical home system stratified by geographic location, age, race, etc.
- Knowledge about any existing organizations or groups that currently support or sustain implementation of medical homes for children
- Knowledge about how care coordination, care planning, shared decision making and effective family-centered care achieves goals for children and families with special health care needs
2. Medical Home Policies & Strategies
- Knowledge of approaches to and challenges in sharing health records in medical home systems and with community partners such as mental health systems
- Knowledge of specific Affordable Care Act (ACA) provisions that address and help finance medical homes for children, especially ramifications of Section 2703 to develop health home services for Medicaid beneficiaries with chronic conditions
- Knowledge of value-based health care and how it affects and informs care for children and youth with special health care needs
- Knowledge about elements of the 11 medical home components that are not traditionally billable
- Knowledge about the potential role of telemedicine in medical home systems, particularly in areas with hard to reach populations and barriers to access
See other online learning resources related to health transformation, collected in the Health Transformation Learning Laboratory.
1 Health Resources and Services Administration. 2014. Title V Maternal and Child Health Services Block Grant to States Program: Guidance and Forms for the Title V Application/Annual Report, Appendix F, p .84.