Title V Transformation Tools
Recommendations to Support NPM 12 – Transition
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 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, 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.
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) transition background, recommendations, and guidelines and (2) transition 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.
- Ability to conduct surveillance of adolescents who should be transitioning into adult care each year using state-specific transition tables from the 2009-10 National Survey of Children with Special Health Care Needs (NSCSHCN) or other state-specific data sources that allows public health practitioners to understand and respond to disparities in transition rates
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 employ qualitative methods in needs assessments with families, providers and communities to identify attitudes about and root causes of low use of transition services
- Ability to align health care transition efforts with other life skills initiatives for young adults
- Ability to perform a strengths-opportunities-weaknesses-threat analyses to consider ways to best support transition within the state/territory
- Skills in quality improvement to support providers and health systems in making data-informed decisions
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 effectively convene diverse partners in establishing a common goal around coordination of transition, including:
- Health care systems
- Health care providers
- Education systems
- Behavioral health
- Disability support and advocacy organizations
- Organizations representing families, youth, and youth adults with special health care needs
- Ability to build capacity at local level to facilitate coalitions of partners to mobilize around transition planning
- Ability to work with state pediatric, family medicine, internal medicine, and nursing leadership to expand educational efforts about evidence-informed transition efforts
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 effectively engage and partner with families/caregivers, youth and young adults in transition quality improvement efforts
- Ability to connect with existing patient navigators and care coordination systems to align transition efforts
- Skills to facilitate self-determination, leading to independence for youth, in systems where Title V programs are directly responsible for transition
- Utilize the Got Transition assessment tools to do an initial assessment and document improvement of involvement of youth and families in their transition approach
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.
- Ability to critically review transition strategies and measures suggested by MCHB and Got Transition
- Ability to analyze when efforts should move beyond programs and clinics toward supporting broader system changes that support funding of transition, especially for youth with special health care needs
- Ability to leverage the Affordable Care Act (ACA) provisions that allow children to stay on parent insurance through the age of 26
- Ability to determine legal authority behind existing memoranda of understanding with governmental agencies in regard to transition services
- Skills to develop memoranda of understanding with Medicaid and other payers to develop policies that ensure effective transition
- Ability to work with state pediatric, family medicine, internal medicine, and nursing leadership to expand educational efforts of evidence-based transition efforts
- Ability to include measurements of family perspectives in program evaluation plans
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 effectively communicate with families, youth and adults about the importance of early and ongoing transition planning, especially for those with special health care needs
- Ability to use life course language to communicate importance of transition services
- Ability to adapt transition language to make it understandable for individuals outside MCH programs
- Ability to effectively communicate positively with both pediatric and adult leaders, medical educators, and clinicians about evidence-based transition strategies
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. Transition Background, Recommendations & Guidelines
- Knowledge of varying definitions of transition, as defined by health care providers and public health practitioners in the state/territory
- Knowledge of typical development and critical determinants of health for older adolescents
- For a health care delivery system within a given state/territory, knowledge of:
- How the system currently approaches transition for young adults with special health care needs
- The difference in transition practices for young adults without special health care needs
- The role of Title V programs in funding services for older adolescents
- Knowledge of current clinical recommendations for adolescent health care, including Bright Futures
- Knowledge of current clinical recommendations and measures for effective transition to adult health care services
- Knowledge of benefits of effective transition to adult health care services
- Knowledge of federal and state centers available to support successful implementation of transition
2. Transition Policies & Strategies
- Knowledge of essential components of the Affordable Care Act (ACA) and other state and federal policies that facilitate effective transition for adolescents, especially for those with special health care needs, such as reimbursable care coordination services
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. 85.