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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 Standards and Guidelines

Approach. Establish a care coordination program using the care coordination standards and guidelines to increase quality care coordination for children.

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Overview. The implementation of a care coordination program leads to improvements in health outcomes for the children and their families, as evidenced by the reduction in hospital admissions and length of stay. These outcomes indicate better management of medical complexity and potentially improved health status for the children involved. Successful care coordination was achieved when a team forms authentic healing relationships, and fosters trust, confidence, and more fruitful communication.This approach results in care plans tailored to the needs of each family, patient, and provider.[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:

  • Care Coordination Quality Measures for Primary Care survey
  • Care coordination fidelity data
  • Patient-reported measures on quality of life 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.
  • Patient Experience of Care. This study improves individuals' perceptions, feelings, and satisfaction with the healthcare services they receive.
  • 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. Collaboration (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 organizations partnered with Title V implementing evidence-based care coordination standards for children. (Measures uptake of best practices)
  • Number of children with special healthcare needs supported by Title V enrolled in guideline-based care coordination programs. (Assesses reach of standardized services)

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

  • Percent of care coordination encounters meeting all core components of applicable standards. (Assesses process quality according to guidelines)
  • Percent of care coordination staff completing training based on established standards. (Measures workforce competency)

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

  • Number of families agreeing that care coordination services are responsive to their needs and preferences. (Measures family-reported satisfaction)
  • Number of care coordination quality measures identified by Title V meeting or exceeding national benchmarks. (Assesses comparative effectiveness)
  • Number of organizations institutionalizing guideline-based coordination as a core strategy for improving outcomes. (Measures institutionalization at system level)
  • Number of regions establishing learning health systems to support continuous improvement of guideline-based coordination. (Assesses quality improvement infrastructure)

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

  • Percent of families agreeing that care coordination services are responsive to their needs and preferences. (Measures family-reported satisfaction)
  • Percent of care coordination quality measures identified by Title V meeting or exceeding national benchmarks. (Assesses comparative effectiveness)
  • Percent of organizations institutionalizing guideline-based coordination as a core strategy for improving outcomes. (Measures institutionalization at system level)
  • Percent of regions establishing learning health systems to support continuous improvement of guideline-based coordination. (Assesses quality improvement infrastructure)

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] Sadof, M., Carlin, S., Brandt, S., & Maypole, J. (2019). A Step-by-Step guide to building a complex care coordination program in a small setting. Clinical Pediatrics, 58(8), 897–902. https://doi.org/10.1177/0009922819849057

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.