Skip Navigation

Strengthen the Evidence for Maternal and Child Health Programs

Sign up for MCHalert eNewsletter

Evidence Tools
MCHbest. Medical Home: Care Coordination.

MCHbest Logo

Strategy. Social Workers

Approach. Promote social workers in a foster care medical home to lead care coordination so more children will receive needed referrals.

Return to main MCHbest page >>

Overview. Children in foster care have a multitude of care coordination needs, including medical, behavioral, and social needs. Social workers have the specific skills necessary to meet these needs, including expertise and in administering behavioral support for families and health system navigation. Research indicates that this level of care coordination leads to reduced emergency department visits, fewer placement disruptions, and less privacy violations among children in foster care.[1]

Evidence. Emerging Evidence. Strategies based on emerging evidence show promise but have not undergone extensive testing. While these approaches demonstrate potential, their effectiveness remains unconfirmed. Prioritize rigorous monitoring to ensure they achieve desired outcomes for all MCH populations.

Access the peer-reviewed evidence through the MCH Digital Library or related evidence source.

Potential Data Sources. Data to support this strategy can be accessed through:

  • Care coordination data
  • Adoption and foster care analysis and reporting system data
  • Referral issuance and completion data

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.
  • Quality of Care. This strategy promotes the degree to which healthcare services meet established standards aimed at achieving optimal health outcomes.
  • Utilization. This strategy improves the extent to which individuals and communities use available healthcare services.

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. Community-Focused

Examples from the Field. There are currently no ESMs that use this strategy. Search similar intervention components in the ESM database.

Sample ESMs. Here are sample ESMs to use as models for your own measures using the RBA framework (see The Role of Title V in Adapting Strategies).

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

  • Number of foster care medical homes integrating social workers into care teams. (Measures adoption of social work integration strategy)
  • Number of children in foster care assigned a social worker care coordinator. (Assesses patient coverage of social work-led coordination)

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

  • Percent of social worker coordinators with specialized training in foster care needs. (Measures workforce competency for foster care population)
  • Percent of care coordination encounters addressing comprehensive needs of children in foster care. (Assesses holistic approach to care coordination)

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

  • Number of children in foster care reporting high satisfaction with social worker coordinators who received training from Title V. (Measures patient experience of social work-led coordination)
  • Number of cross-sector partnerships led by Title V formed to facilitate social worker-led care linkages who report high levels of engagement. (Measures care coordination infrastructure)
  • Number of healthcare systems adopting social worker integration as a standard for foster care coordination. (Measures systems change impact of social work model)
  • Number of communities experiencing improved outcomes for children in foster care through social work-led coordination. (Assesses population health impact)

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

  • Percent of children in foster care reporting high satisfaction with social worker coordinators who received training from Title V. (Measures patient experience of social work-led coordination)
  • Percent of cross-sector partnerships led by Title V formed to facilitate social worker-led care linkages who report high levels of engagement. (Measures care coordination infrastructure)
  • Percent of healthcare systems adopting social worker integration as a standard for foster care coordination. (Measures systems change impact of social work model)
  • Percent of communities experiencing improved outcomes for children in foster care through social work-led coordination. (Assesses population health impact)

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] Hoffmann, L. M., Woods, M. L., Vaz, L. E., Blaschke, G. S., & Grigsby, T. (2021). Measuring care coordination by social workers in a foster care medical home. Social Work in Health Care, 60(5), 467–480. https://doi.org/10.1080/00981389.2021.1944452

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.