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Strengthen the Evidence for Maternal and Child Health Programs

New: MCHbest strategies database for sample ESMs

Evidence Tools
MCHbest. NPM 11: Medical Home

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Strategy. Dedicated Care Coordinators

Approach. Use dedicated care coordinators to develop relationships with families to increase timely attendance of well-child visits and respond to the needs of families.

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Overview. Research shows that designating a care coordinator with protected time to make outreach calls and identify patient needs were effective strategies for improving connections to the medical home. The care coordinator can identify and coordinate care with patients while establishing early relationships by making “welcome calls” to families congratulating them on the baby, welcoming them to the practice, reminding them of their appointments, and acting as the point-of-contact for caregiver’ concerns. The care coordinator can also serve as a critical component in connecting and referring families to needed services or community organizations outside of the provider’s office.1 Alternatively, the care coordinator role can also be part of a home visiting program (see strategies for Strengthening Service Coordination Between Home Visitors and Pediatric Primary Care Providers).

The Role of Title V. Many Title V CYSHCN programs are using care coordination in many different approaches. While the evidence has found effectiveness of dedicated staff/time for a care coordinator, it’s recognized that many Title V programs are looking to divest of such efforts due to cost. In thinking of how this strategy could be approached from a systems perspective, think of ways that Title V funds could be used to provide training or outreach services for care coordination efforts currently in the state/jurisdiction. A potential activity for a related Title V activity in support of dedicated care coordinators could be to identify lists of resources/supports within the state/jurisdiction or community to help with referrals. For systems-based ideas of how to incorporate care coordination to advance participation in a medical home model, see the National Standards for Children and Youth with Special Health Care Needs: Medical Home.

Evidence. Emerging Evidence. The study supporting this intervention provides data indicating that the intervention may be effective. However, the study includes limited research documenting effects and requires further research to confirm effects. More research is needed for conclusive results. Access the peer-reviewed evidence through the MCH Digital Library (link coming soon). (Read more about understanding evidence ratings).

Target Audience. Provider/Practice and Home Visiting Program.

Outcome. Increased well-visits and increased home visiting program participation. For detailed outcomes related to each study supporting this strategy, click on the peer-reviewed evidence link above and read the "Intervention Results" for each study.

Examples from the Field. There are currently 6 ESMs across all states/jurisdictions that use this strategy directly or intervention components that align with this strategy. Access descriptions of these ESMs through the MCH Digital Library. You can use these ESMs to see how other Title V agencies are addressing the NPM.

Sample ESMs. Using the approach “Designate a care coordinator with protected time to make outreach calls and respond to the needs of families,” here are sample ESMs you can use as a model for your own measures using the Results-Based Accountability framework (for suggestions on how to develop programs to support this strategy, see The Role of Title V in Adapting Strategies):

Quadrant 1:
Measuring Quantity of Effort
("What/how much did we do?")

  • Number of welcome/outreach calls by care coordinators to families annually to connect infants/children to care within the medical home model.
  • Number of families who receive a referral to a local home visiting program to address needs.

Quadrant 2:
Measuring Quality of Effort
("How well did we do it?")

  • Percent of families who received targeted support from the care coordinator.

Quadrant 3:
Measuring Quantity of Effect
("Is anyone better off?")

  • Number of families who, upon completion of calls, indicate that they received helpful and appropriate advice from care coordinator.
  • Number of families that report using the referral for home visiting services.
  • Number of families who report positive experience of care integration of child health through the Pediatric Integrated Care Survey (PICS).
  • Number of families who followed through with referrals to other providers or to community resources.

Quadrant 4:
Measuring Quality of Effect
("How are they better off?")

  • Percent of families who report more timely well-child visits and connection to a medical home model of care due to efforts by the care coordinator.
  • Percent of families who report positive experience of care integration of child health through the Pediatric Integrated Care Survey (PICS).
  • Percent of families who followed through with referrals to other providers or to community resources.

Note. ESMs become stronger as they move from measuring quantity to measuring quality (moving from Quadrants 1 and 3, respectively, to Quadrants 2 and 4) and from measuring effort to measuring effect (moving from Quadrants 1 and 2, respectively, to Quadrants 3 and 4).

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.


1 Brown, C. M., Perkins, J., Blust, A., & Kahn, R. (2015). A neighborhood-based approach to population health in the pediatric medical home. Journal of Community Health, 40(1), 1-11.

Additional Resources:

This Manual is intended to assist users of the Pediatric Integrated Care Survey (PICS) to optimally adapt and employ the instrument. The Pediatric Integrated Care Survey was developed to measure the family-reported experience of care integration of child health, broadly defined. The outcomes are intended to inform quality improvement efforts


This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.