Theory of Change

Problem Statement:

The traditional health care system is not working optimally to provide access to timely, appropriate, quality prevention and care for children and their families living within or near the federal poverty guidelines.

Intervention:

Develop a model that tests an alternative approach to address health care needs of low-income children and families, primarily in their local school setting. Create an interdisciplinary team of health and social service providers where the child’s needs are central, but the entire family’s needs are addressed. The team will connect the child/family to a medical home and other relevant health and social services, as well as help them navigate the system, including better understanding of the benefits of prevention and wellness.

Goal(s):

Integrate health and wellness into the social fabric of the community. Position schools to be seen and used as a broader community asset and key element of a community environment that protects and actively promotes health. Coordinate medical and social support for greater child and family health and wellness. Encourage and enable people to make healthy choices for themselves and their families.

Premise:

Bringing physical and mental health care one step closer to families in their local school setting can directly improve their access to care as well as encourage them to take greater responsibility. Providing an early medical home to a child increases his/her chance for better direct health as well as developing health and wellness as an essential element of their lifestyle. Medical resources can be more productively and efficiently deployed.

Potential Activities:

directory of health services for broad distribution in the community
demonstration project in school (create a school-based health center)
ancillary services that broaden reach such as a mobile van
education and involvement of employers as reinforcement for changes in schools

Indicators:

Children and their families have an identified medical home
Children and their families are enrolled in/take advantage of all eligible health coverage plans and other benefits programs (EITC, etc.)
Reduction in utilization of ERs as medical homes

Outcomes:

Client-level—Children and their families see the benefits of prevention and wellness; adopt new patterns and move closer to optimal health status
Provider-level—More productive use of limited and expensive resources
Systems level—Schools are utilized as an essential community asset to provide holistic health and social services