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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Forgone Health Care.

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Strategy. Care Coordination and Case Management

Approach. Establish care coordination and case management programs that assist families in navigating the healthcare system and overcoming barriers to care

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Overview. By addressing the complex needs of CYSHCN across various sectors and providing support in accessing services, care coordination and case management can help prevent situations where children may forego necessary health care due to barriers or challenges in the healthcare system. High-quality and efficient care coordination requires an understanding of the specific needs of CYSHCN and their families and how to link them to a diverse array of services and resources. Care coordination and case management programs can assist families in navigating the healthcare system, scheduling appointments, and accessing necessary services, as well as provide support and follow-up for families with complex healthcare needs. By facilitating timely access to services, promoting continuity of care, and optimizing well-being for CYSHCN and their families, care coordination can help ensure that children receive the necessary health care services they require, reducing the likelihood of forgone health care. Additionally, care coordination is associated with favorable family and provider partnerships, positive family and child outcomes, and increased patient and family satisfaction.[1]

Evidence. Emerging Evidence. Strategies with this rating typically trend positive and have good potential to work. They often have a growing body of recent, but limited research that documents effects. However, further study is needed to confirm effects, determine which types of health behaviors and conditions these interventions address, and gauge effectiveness across different population groups. (Clarifying Note: The WWFH database calls this "mixed evidence").

Access the peer-reviewed evidence through the MCH Digital Library or related evidence source. (Read more about understanding evidence ratings).

Source. Peer-Reviewed Literature

Outcome Components. This strategy has shown to have impact on the following outcomes (Read more about these categories):

  • Access to/Receipt of Care. This strategy increases the ability for individuals to obtain healthcare services when needed, including preventive, diagnostic, and treatment services.
  • Timeliness of Care. This strategy promotes delivery of healthcare services in a timely manner to optimize benefits and prevent complications.
  • Patient Experience of Care. This study improves individuals' perceptions, feelings, and satisfaction with the healthcare services they receive.

Detailed Outcomes. For specific outcomes related to each study supporting this strategy, access the peer-reviewed evidence and read the Intervention Results for each study.

Intervention Type. Case Management (Read more about intervention types and levels as defined by the Public Health Intervention Wheel).

Intervention Level. Individual/Family-Focused

Examples from the Field. There are currently no ESMs that use this strategy. As Title V agencies begin to incorporate this strategy into ESMs, examples will be available here. Until then, you can search for ESMs that have similar intervention components in the ESM database.

Sample ESMs. Here are sample ESMs to use as models 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?")

PROCESS MEASURES:

  • Number of care coordination and case management programs established to assist families in navigating the healthcare system. (Measures availability of support services.)
  • Number of families enrolled in care coordination and case management programs. (Captures program reach and engagement.)
  • Number of care coordinators and case managers trained to identify and address barriers to care for children and families. (Assesses workforce capacity building.)

OUTCOME MEASURES:

  • Number of children who receive needed health care services as a result of care coordination and case management support. (Measures impact on access to care.)
  • Number of families connected to enabling services (e.g., transportation, language assistance) through care coordination and case management. (Indicates reduction of barriers.)
  • Number of children who avoid missed or delayed care due to the assistance of care coordinators and case managers. (Demonstrates prevention of forgone care.)

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

PROCESS MEASURES:

  • Percent of care coordination and case management encounters that include comprehensive assessment of children's health needs and family circumstances. (Measures holistic approach.)
  • Percent of care plans developed through care coordination and case management that are culturally appropriate and tailored to family preferences. (Assesses family-centered care.)
  • Percent of care coordinators and case managers who demonstrate proficiency in culturally competent communication and trauma-informed practices. (Evaluates workforce skills.)

OUTCOME MEASURES:

  • Percent of children referred to needed services who successfully access care with the help of care coordination and case management. (Captures successful care linkages.)
  • Percent of families who report improved understanding of their children's health needs and confidence navigating the healthcare system after receiving support. (Measures empowerment.)
  • Percent of children with chronic conditions who experience improved health outcomes and reduced complications through care coordination and case management. (Assesses clinical impact.)

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

PROCESS MEASURES:

  • Number of healthcare organizations that integrate care coordination and case management into their standard operations. (Captures systems-level adoption.)
  • Number of cross-sector partnerships (e.g., with schools, social services) established to strengthen care coordination and case management for children. (Measures collaborative action.)
  • Number of policies and payment models implemented to sustain care coordination and case management programs. (Assesses strategies for long-term viability.)

OUTCOME MEASURES:

  • Number of communities that demonstrate sustained reductions in child foregone health care rates after implementing care coordination and case management programs. (Measures population health impact.)
  • Number of school days saved and developmental milestones achieved as a result of children receiving timely care through coordinated support. (Captures cross-sector impact.)
  • Number of families who gain economic stability and self-sufficiency due to improved child health and reduced caregiving burden. (Indicates family well-being impact.)

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

PROCESS MEASURES:

  • Percent of care coordination and case management programs that prioritize outreach and engagement of families experiencing health disparities. (Measures equity focus.)
  • Percent of families from underserved communities who are connected to care coordinators and case managers that reflect their cultural and linguistic backgrounds. (Assesses representation.)
  • Percent of care coordination and case management initiatives that involve partnerships with community-based organizations trusted by marginalized populations. (Evaluates community engagement.)

OUTCOME MEASURES:

  • Percent reduction in disparities in foregone care between children from disadvantaged backgrounds and those from more privileged circumstances. (Measures equity impact.)
  • Percent of children from historically underserved communities who receive all recommended preventive care and screenings through care coordination and case management. (Assesses equitable access.)
  • Percent decrease in excess disease burden and avoidable complications among children of color and those from low-income families due to timely access to coordinated care. (Demonstrates health equity progress.)

Note. When looking at your ESMs, SPMs, or other strategies:

  1. Move from measuring quantity to quality.
  2. Move from measuring effort to effect.
  3. Quadrant 1 strategies should be used sparingly, when no other data exists.
  4. The most effective measurement combines strategies in all levels, with most in Quadrants 2 and 4.

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

References

[1] Roman, S. B., Dworkin, P. H., Dickinson, P., & Rogers, S. C. (2020). Analysis of Care Coordination Needs for Families of Children with Special Health Care Needs. Journal of developmental and behavioral pediatrics : JDBP, 41(1), 58–64.

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.