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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Medical Home: Care Coordination.

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Strategy. Care Coordination for Children with Medical Complexity

Approach. Establish care coordination for children with medical complexity to meet their early and comprehensive needs.

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Overview. Care coordination programs are beneficial for children with complex medical needs.[1,2] Implementing a longitudinal care coordination program can effectively address the unique needs of families of infants with medical complexity throughout the first year of life.[1] Programs can be used as translatable models in NICUs elsewhere to address the unique needs of families of infants with medical complexity throughout the first year of life.[1] Enrolling children with complex chronic conditions in a care coordination program after hospital discharge can lead to lower hospitalization rates.[2] Providers reported that smaller caseloads were central to the success of care coordination programs.[1]

Evidence. Moderate Evidence. Strategies based on moderate evidence show a clear trend toward positive results. While these approaches are likely to be effective, further research is needed to confirm their impact. Implement with evaluation to better understand specific local effects.

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:

  • Family experiences with care coordination survey
  • Care coordination measurement tool
  • Shared plan of care documentation fidelity audits

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

  • Patient Experience of Care. This study improves individuals' perceptions, feelings, and satisfaction with the healthcare services they receive.
  • Quality of Care. This strategy promotes the degree to which healthcare services meet established standards aimed at achieving optimal health outcomes.
  • Access to/Receipt of Care. This strategy increases the ability for individuals to obtain healthcare services when needed, including preventive, diagnostic, and treatment 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 healthcare organizations implementing specialized care coordination for children with medical complexity. (Measures adoption of complex care coordination services)
  • Number of children with medical complexity enrolled in comprehensive care coordination services. (Assesses reach of complex care coordination)

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

  • Percent of care coordination services adhering to evidence-based practices for complex care. (Assesses fidelity of complex care coordination implementation)
  • Percent of care plans that are individualized and responsive to each child and family's unique needs. (Shows person-centeredness of coordination approach)

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

  • Number of families reporting high satisfaction and shared decision-making in care coordination experiences. (Measures experience of care and family-provider collaboration)
  • Number of research initiatives advancing the evidence base for complex care coordination that results in an increase in workforce knowledge and/or skill. (Shows knowledge generation efforts)
  • Number of communities demonstrating improved health outcomes for children with medical complexity through care coordination. (Assesses population health impact)
  • Number of policies influenced by lessons learned from complex care coordination initiatives. (Shows broader systems change impact)

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

  • Percent of care coordination programs co-designed with families and community partners. (Measures authentic engagement in program development)
  • Percent of coordination teams including family navigators to address non-medical influences on health. (Shows workforce engagement in complex care coordination)
  • Percent reduction in negative health outcomes among children with medical complexity. (Measures impact of care coordination)
  • Percent of families reporting increased trust and capability in navigating healthcare systems through care coordination support. (Assesses family-reported outcomes in healthcare navigation)

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] Dallas, A., Ryan, A., Mestan, K. K., Helner, K., & Foster, C. C. (2022). Family and provider experiences with longitudinal care coordination for infants with medical complexity. Advances in Neonatal Care, 23(1), 40–50. https://doi.org/10.1097/anc.0000000000000998

[2] Parker, C. L., Wall, B., Tumin, D., Stanley, R., Warren, L. R., Deal, K., Stroud, T., Crickmore, K., & Ledoux, M. (2020). Care Coordination program for children with complex chronic conditions discharged from a rural Tertiary-Care Academic Medical Center. Hospital Pediatrics, 10(8), 687–693.

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.