Inventory of Evidence-Based Practices (EBPs) for Healthy Start Programs

Evidence-based practices include actions, activities, strategies, or approaches that improve the health of women, before, during, and after pregnancy in order to improve birth outcomes and give infants up to age two years a healthy start. Also included in the collection are informational materials and tools that make it easier to implement evidence-based practices. To search by title, use the main search box located at the top of this page.

You searched for: Case Management/Care Coordination

Number of results: 20


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Rural Behavioral Health: Telehealth Challenges and Opportunities

This brief looks at common acceptability, availability, and accessibility barriers to mental and substance use disorder (behavioral health) treatment and services in rural communities and presents ways telehealth can help surmount some of these barriers. The term telehealth refers to using internet and communications technologies, such as videoconferencing, chat, and text messaging, to provide health information and treatments in real time.

Topics:

Alcohol/Drug Services Case Management/Care Coordination Depression

Approaches:

Strengthen Family Resilience

Benchmarks:

Perinatal Depression Follow Up Perinatal Depression Screening

Evidence Rating: II. Promising practices—Innovative practices employed in the field, based on state-of-science knowledge about what works to improve outcomes, and gathering evidence of effectiveness.

Alcohol Screening and Brief Intervention: A guide for public health practitioners

Screening and brief intervention (SBI) is a structured set of questions designed to identify individuals at risk for alcohol use problems, followed by a brief discussion between an individual and a service provider, with referral to specialized treatment as needed. This manual is designed to provide public health professionals, such as health educators and community health workers, with the information, skills, and tools needed to conduct SBI so that they can help at-risk drinkers reduce their alcohol use to a safe amount or stop drinking. The manual offers background information and practical steps for conducting SBI in a variety of public health settings, including trauma centers, emergency departments, other clinical settings, home visits, and public events.

Topics:

Alcohol/Drug Services Case Management/Care Coordination Risk Assessment

Approaches:

Improve Women's Health

Benchmarks:

Well Woman Visits

Evidence Rating: II. Promising practices—Innovative practices employed in the field, based on state-of-science knowledge about what works to improve outcomes, and gathering evidence of effectiveness.

AIM Patient Safety Bundles

The Alliance for Innovation on Maternal Health (AIM) is a national data-driven maternal safety and quality improvement initiative based on proven implementation approaches to improving maternal safety and outcomes in the U.S. The AIM supported safety bundles are collections of evidence based protocols and best practices for improving safety in maternity care, and handling obstetric complications and emergencies in hospital and outpatient settings. AIM provides implementation and data support for each AIM supported patient safety bundle.

Topics:

Case Management/Care Coordination Other Prenatal Care and Education Risk Assessment

Approaches:

Improve Women's Health

Benchmarks:

Postpartum Visit

Evidence Rating: II. Promising practices—Innovative practices employed in the field, based on state-of-science knowledge about what works to improve outcomes, and gathering evidence of effectiveness.

Black Mamas Matter: Advancing the Human Right to Safe and Respectful Maternal Health Care

This toolkit provides a foundation, framework and resources for advancing maternal health in the U.S. as a human rights issue. It provides a research overview of maternal morbidity and mortality, focusing on trends, health disparities and inequities. Based on the deliberations of a cross-sectoral convening of stakeholders it offers a state policy framework for upholding the right to safe and respectful maternal health care, which offers recommendations in six key areas: improving access to reproductive health care, improving quality of maternal health care, ensuring acceptability of maternal health care for women most at risk, ensuring widespread availability of maternal health services, ensuring non-discrimination in access to care and social determinants of health, and fostering accountability to human rights standards for maternal health care.

Topics:

Case Management/Care Coordination Home Visiting Insurance Coverage Life Course Model Patient-centered Medical Home Prenatal Care and Education Reproductive Life Planning/Family Planning

Approaches:

Improve Women's Health

Benchmarks:

Health Insurance Postpartum Visit Well Woman Visits

Evidence Rating: III. Expert guidelines—Protocols, standards of practice, or recommendations based on expert consensus.

Pregnancy & Opioids: What families need to know about opioid misuse and treatment during pregnancy

This guide provides information and resources for family members and friends on specific ways to support pregnant women with opioid use disorders, and help them to get the prenatal care, substance use treatment and other supports they need during pregnancy and postpartum.

Topics:

Alcohol/Drug Services Case Management/Care Coordination Prenatal Care and Education

Approaches:

Improve Women's Health Strengthen Family Resilience

Benchmarks:

Perinatal Depression Follow Up Usual Source of Care

Evidence Rating: III. Expert guidelines—Protocols, standards of practice, or recommendations based on expert consensus.

Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition)

This update of the National Institute on Drug Abuse’s Principles of Drug Addiction Treatment is intended to address addiction to a wide variety of drugs, including nicotine, alcohol, and illicit and prescription drugs. It is designed to serve as a resource for healthcare providers, family members, and other stakeholders trying to address the myriad problems faced by patients in need of treatment for drug abuse or addiction. It provides an overview of principles of effective treatment and evidence-based approaches to treatment, including behavioral therapies, pharmacotherapies and comprehensive approached. It discusses the unique needs of different groups including women, pregnant women and adolescents.

Topics:

Alcohol/Drug Services Case Management/Care Coordination Tobacco Cessation

Approaches:

Improve Women's Health Promote Quality

Benchmarks:

Smoking Abstinence

Evidence Rating: II. Promising practices—Innovative practices employed in the field, based on state-of-science knowledge about what works to improve outcomes, and gathering evidence of effectiveness.

A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders

This guide is intended to support the efforts of states, tribes, and local communities in addressing the needs of pregnant women with opioid use disorders and their infants and families, through a coordinated, multi-sytem approach. The guide is designed to assist healthcare providers, SUD treatment providers, child welfare programs and judicial systems to improve their collaborative practice, and to offer information about additional resources that will strengthen their capacity to provide coordinated, best-practice care and services Collaborative planning and implementation of services that reflect best practices for treating opioid use disorders during pregnancy are yielding promising results in communities across the country. .

Topics:

Alcohol/Drug Services Case Management/Care Coordination Patient-centered Medical Home Prenatal Care and Education

Approaches:

Improve Women's Health

Benchmarks:

Evidence Rating: II. Promising practices—Innovative practices employed in the field, based on state-of-science knowledge about what works to improve outcomes, and gathering evidence of effectiveness.

Changing Systems & Practice to Improve Outcomes for Young Fathers, Their Children & Their Families

This policy report highlights the need to support young fathers by providing recommendations for child welfare system policy and practice change. Research shows that the relationship between fathers and their children is essential to the well-being of families and the healthy development of children, however little attention is paid to the importance of engaging young fathers under age 26, particularly young fathers who are involved with child welfare systems. This report provides recommendations on how systems can better focus on father involvement to increase positive outcomes for fathers, their children and families.

Topics:

Case Management/Care Coordination Intimate Partner Violence Parenting Education Participant Recruitment and Retention Partner Involvement

Approaches:

Strengthen Family Resilience

Benchmarks:

Father/Partner Parenting Involvement Father/Partner Prenatal Involvement

Evidence Rating: III. Expert guidelines—Protocols, standards of practice, or recommendations based on expert consensus.

IPV Health Partners Toolkit

This toolkit is designed to help health centers to build a comprehensive and sustainable response to domestic violence and sexual assault (DV/SA) in partnership with DV/SA advocacy programs (social service organizations).Through five essential steps, health centers and social service partners can build partnerships, adopt evidence-based interventions, promote patient education around IPV, and enhance practice policies, procedures, and capacities to improve long-term health and safety outcomes for women and their families.

Topics:

Case Management/Care Coordination Intimate Partner Violence Patient-centered Medical Home Risk Assessment

Approaches:

Strengthen Family Resilience

Benchmarks:

Intimate Partner Violence

Evidence Rating: III. Expert guidelines—Protocols, standards of practice, or recommendations based on expert consensus.

AAP Fetal Alcohol Spectrum Disorders Toolkit

The American Academy of Pediatrics FASD Toolkit was developed in coordination with the CDC to raise awareness, promote surveillance and screening, and ensure that all children who possibly have FASDs receive appropriate and timely interventions. Focused primarily on providers, it features basic information on FASD, diagnostic tools for use in children suspected of being affected, evidence-based interventions, and guidelines for case management/care coordination. The site also contains FAQ and a list of resources for families and school professionals who care for children with FASD.

Topics:

Alcohol/Drug Services Case Management/Care Coordination Parenting Education

Approaches:

Benchmarks:

Evidence Rating: III. Expert guidelines—Protocols, standards of practice, or recommendations based on expert consensus.

Moving Beyond Depression

Moving Beyond Depression (MBD) is a comprehensive, evidence-based and integrated approach to identifying and treating depression in mothers participating in home visitation programs. When new mothers are depressed, home visitation programs face challenges in helping them. MBD equips home visiting programs with a complete package that helps them identify, treat, and provide ongoing support to mothers experiencing depression. MBD is adapted for the “real world” and designed to be engaging and relevant to young, low-income, new mothers. The program works to establish strong working relationships between home visitors and therapists, who collaborate closely through treatment. By treating moms in their own homes, it overcomes many barriers to treatment, such as lack of access to mental health care, transportation and childcare, among others.

Topics:

Case Management/Care Coordination Depression Home Visiting

Approaches:

Strengthen Family Resilience

Benchmarks:

Perinatal Depression Follow Up

Evidence Rating: I. Evidence-based practices—have been rigorously evaluated and shown to be effective by MCH experts.

National Center for Medical-Legal Partnership

Medical‐legal partnership (MLP) is an approach to health that integrates the work of healthcare, public health, and civil legal aid to more effectively identify, treat, and prevent health‐harming legal needs for patients, clinics, and populations. MLP addresses legal needs in the areas of income supports and insurance; housing and utilities; employment and education; legal status; and personal and family stability. MLP:

  • Trains healthcare, public health, and legal teams to work collaboratively and identify needs upstream;
  • Treats individual patients’ health‐harming social and legal needs with legal care ranging from triage and consultations to legal representation;
  • Transforms clinic practice and institutional policies to better respond to patients’ health‐harming social and legal needs; and
  • Prevents health‐harming legal needs broadly by detecting patterns and improving policies and regulations that have an impact on population health. 

Topics:

Case Management/Care Coordination Insurance Coverage Other Risk Assessment

Approaches:

Achieve Collective Impact Improve Women's Health

Benchmarks:

CAN Implementation Health Insurance

Evidence Rating: II. Promising practices—Innovative practices employed in the field, based on state-of-science knowledge about what works to improve outcomes, and gathering evidence of effectiveness.

Partners in Pregnancy

The Partners in Pregnancy program aims to improve pregnancy outcomes for high-risk pregnancies through home visits by nurses and outreach workers, in combination with a medical home and regular nurse consultations. Studies suggest that the program has reduced neonatal intensive care unit use and overall costs, due to more patients receiving comprehensive prenatal care and adopting healthier behaviors.

Topics:

Case Management/Care Coordination

Approaches:

Improve Women's Health

Benchmarks:

Usual Source of Care

Evidence Rating: II. Promising practices—Innovative practices employed in the field, based on state-of-science knowledge about what works to improve outcomes, and gathering evidence of effectiveness.

Healthy Families America

Designed for parents facing challenges including single parenthood, low income, and history of domestic violence, substance abuse, or mental health issues. Families are enrolled prenatally or at birth, and services are provided until the child’s 3rd or 5th birthday. Includes 1 home visit a week for the first 6 months, and less frequent visits after the child is 6 months of age.

Topics:

Case Management/Care Coordination Home Visiting Parenting Education

Approaches:

Strengthen Family Resilience

Benchmarks:

Father/Partner Parenting Involvement Father/Partner Prenatal Involvement Perinatal Depression Screening

Evidence Rating: I. Evidence-based practices—have been rigorously evaluated and shown to be effective by MCH experts.

Every Child Succeeds

Provides home visits focused on child development to first-time at-risk mothers, from pregnancy until the child’s third birthday. Goals are to decrease abuse and neglect, reduce unintentional injuries, strengthen the parent-child relationship, improve utilization of diagnostic services, encourage good health practices, link families with primary care, promote an optimal environment for learning and emotional growth, encourage development and self-care of mothers, and begin the school readiness process. ECS uses both the Healthy Families America and Nurse-Family Partnership models. Evaluation showed a 60% reduction in infant mortality compared to control group, and more children on track for language development.

Topics:

Case Management/Care Coordination Home Visiting Parenting Education

Approaches:

Improve Women's Health Strengthen Family Resilience

Benchmarks:

Father/Partner Parenting Involvement Intimate Partner Violence Reading to Child Daily Usual Source of Care Well Child Visits Well Woman Visits

Evidence Rating: I. Evidence-based practices—have been rigorously evaluated and shown to be effective by MCH experts.

Early Intervention Program (EIP) for Adolescent Mothers

Designed for adolescents (14-19) from underserved minority groups who are pregnant with their first child and planning to keep the infant. Objective is to improve maternal health behaviors during and after pregnancy, improve birth outcomes, build maternal caretaking skills , improve the quality of mother-child interaction, prevent rapid repeat pregnancy, increase educational achievement, and build social competence. Program consists of 2 prenatal and 15 postpartum home visits until the child’s first birthday.

Topics:

Case Management/Care Coordination Home Visiting Parenting Education Reproductive Life Planning/Family Planning

Approaches:

Improve Women's Health

Benchmarks:

Reproductive Life Plan

Evidence Rating: I. Evidence-based practices—have been rigorously evaluated and shown to be effective by MCH experts.

Ohio Perinatal Quality Collaborative (OPQC)

The Ohio Perinatal Quality Collaborative (OPQC) is a statewide consortium of perinatal clinicians, hospitals, and policy makers and governmental entities that aims, through the use of improvement science, to reduce preterm births and improve birth outcomes across Ohio. OPQC uses monthly action period calls and face-to-face sessions with teams to review individual and aggregate data, learn from teams that have been successful at making changes and achieving improved outcomes, and apply the Model for Improvement to test specific strategies. OPQC was founded in 2007, and is seen as a national model in statewide perinatal improvement.

Topics:

Case Management/Care Coordination Prenatal Care and Education Risk Assessment

Approaches:

Promote Quality

Benchmarks:

Reducing Early Elective Deliveries Well Child Visits

Evidence Rating: II. Promising practices—Innovative practices employed in the field, based on state-of-science knowledge about what works to improve outcomes, and gathering evidence of effectiveness.

Prenatal Plus Program

Prenatal Plus is a program that provides care coordination, nutrition and mental health counseling to Medicaid-eligible pregnant women in Colorado who are at a high risk for delivering low birth weight infants. The program uses the client-centered counseling approach with all participants to address a variety of issues that have been shown to have a negative impact on birth outcomes. The key health areas targeted by this program are healthy weight, smoking cessation and depression. The program has been demonstrated to decrease the rate of low-birth weight infants and resolve the risks putting women at risk of delivering low-birth weight infants.

Topics:

Case Management/Care Coordination Depression Healthy Weight Tobacco Cessation

Approaches:

Strengthen Family Resilience

Benchmarks:

Father/Partner Prenatal Involvement Perinatal Depression Follow Up Perinatal Depression Screening

Evidence Rating: II. Promising practices—Innovative practices employed in the field, based on state-of-science knowledge about what works to improve outcomes, and gathering evidence of effectiveness.

The Parent Child Assistance Program (PCAP)

Evidence-based home visitation case-management model for mothers who abuse alcohol and/or drugs during their pregnancies. PCAP’s goals are to assist substance-abusing pregnant women and mothers in obtaining treatment for substance abuse and staying in recovery, to ensure that children are in safe and stable home environments and are connected to health care, to connect mothers to community resources, and to prevent future births of alcohol and drug-affected infants. Piloted in Washington State, PCAP has been replicated in 7 states, and across Canada and New Zealand.

Topics:

Alcohol/Drug Services Case Management/Care Coordination Home Visiting

Approaches:

Improve Women's Health Promote Quality

Benchmarks:

Well Child Visits Well Woman Visits

Evidence Rating: I. Evidence-based practices—have been rigorously evaluated and shown to be effective by MCH experts.

Pathways Model

The Pathways Model employs community health workers who connect at-risk women to evidence-based care using individualized pathways designed to produce healthy outcomes. The model promotes timely, efficient care coordination through incentives. It prevents service duplication by using a Community Hub, a regional point of patient registration, and quality assurance to support a network of agencies involved in providing care to the target population. The first implementation of the model in Richland, Ohio, resulted in increased services to at-risk women and a decline in the rate of low-birth-weight babies.

Topics:

Case Management/Care Coordination

Approaches:

Improve Women's Health Promote Quality

Benchmarks:

Well Child Visits Well Woman Visits

Evidence Rating: II. Promising practices—Innovative practices employed in the field, based on state-of-science knowledge about what works to improve outcomes, and gathering evidence of effectiveness.