The National Maternal and Child Health (MCH) Workforce Development Center is the co-author of a new resource guide about how to implement system-level changes to improve outcomes for children and youth with special health care needs (CYSHCN) and their families.
The Resource Guide for Implementing Complex System Change in Title V CYSHCN Program is designed to help Title V CYSHCN teams plan, implement, and track system-level changes.
Beginning in 2025, we partnered with the National Center for a System of Services for Children and Youth with Special Health Care Needs at the American Academy of Pediatrics (AAP) to develop the guide. To inform the development of the guide, we also gathered input and insights from Title V CYSHCN leaders and family leaders who have firsthand experience implementing system-level innovations for CYSHCN populations in seven states.
Title V CYSHCN programs can use this guide to assess their progress, document key activities, and identify areas for improvement or future planning. It’s designed for flexible use. Teams can use the guide to help build toward sustained and evidence-informed improvements, regardless of the topic they are working on or the stage of their system-level initiative.
The guide includes information about the four phases of implementation, tools, suggested technical assistance providers to support implementation, and case studies to illustrate examples of systems change in action.
The case studies describe four successful system-level initiatives implemented by Title V CYSCHN teams:
- A Pediatric Behavioral Health Collaborative that integrated behavioral health into primary care scaled statewide, improving access and breaking down silos between medical and mental health systems.
- A Pediatric Care Coordination Community of Practice that has fostered broad collaboration among health, education, family, and community stakeholders and engaged 700 care coordinators in process improvement.
- An initiative that created true partnerships with family leaders, embedding person-centered care across programs that serve CYSCHN.
- An effort that transformed developmental screening referrals from a fragmented, fax-based process into a sustainable, statewide electronic closed-loop system.
Each case study also describes “lessons learned,” which can inform similar efforts in other states.
“Systems change goes beyond implementing a single intervention,” said Amy Mullenix, MSW, MSPH, the Deputy Director of the National MCH Workforce Development Center and one of the authors of the guide. “It’s about changing multiple levels of a system simultaneously, while working with partners and adapting to challenges and changes along the way. That’s what can really move the needle on health outcomes for children and their families, and this guide is designed to help teams make that happen.”
Title V CYSCHN teams who have questions about the guide or want support for using the guide to improve outcomes, are welcome to contact us or contact the National Center for a System of Services for CYSCHN.