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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 Coordinators/Case Managers

Approach. Establish care coordinator positions to provide quality care coordination to children.

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Overview. Incorporating a care coordinator position. (regardless of the actual title) that focuses on care coordination results in improved health outcomes for patients.[1-9] In many cases, this professional role aligns with the skill set of a registered nurse.[1-3,5-8] In addition to improved family outcomes [1-2,4-9], care coordination also reduces costs associated with emergency department visits and hospitalizations.[1,3-4,6,9]

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 coordinator caseload activity log
  • Provider and staff satisfaction surveys
  • Care coordinator fidelity 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. 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 organizations establishing dedicated care coordinator positions for children. (Measures adoption of care coordination workforce)
  • Number of children with complex conditions assigned a designated care coordinator. (Assesses reach of care coordination services)

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

  • Percent of care coordinators with specialized training in pediatric care coordination. (Measures workforce competency)
  • Percent of care coordination process actively engaging families in shared decision-making. (Assesses family engagement practices)

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

  • Number of families reporting high satisfaction and trust with their care coordinators. (Measures experience of care)
  • Number of families reporting improved care navigation with coordinator assistance. (Assesses impact on family well-being)
  • Number of healthcare quality measures improved after implementing care coordinator roles. (Measures system performance impact)
  • Number of communities experiencing enhanced pediatric health outcomes through care coordination workforce development. (Assesses population health impact)

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

  • Percent of care coordinators reflecting the makeup of the communities they serve. (Measures workforce representativeness)
  • Percent of care coordination policies prioritizing skills in alliance-building and results in an increase in workforce capacity. (Assesses organizational commitment to capacity)
  • Percent of healthcare quality measures improved after implementing care coordinator roles. (Measures system performance impact)
  • Percent of communities experiencing enhanced pediatric health outcomes through care coordination workforce development. (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] Council on Children with Disabilities and Medical Home Implementation Project Advisory Committee, Turchi, R. M., Antonelli, R. C., Norwood Jr, K. W., Adams, R. C., Brei, T. J., ... & Sia, C. (2014). Patient-and family-centered care coordination: a framework for integrating care for children and youth across multiple systems. Pediatrics, 133(5), e1451-e1460.

[2] McRoberts, C. M., Bohlen, N., & Wills, H. (2019). Bridging the gap: Utilizing a pediatric trauma care coordinator to reduce differences for Pediatric Trauma Follow-Up Care. Journal of Trauma Nursing, 26(4), 193–198. https://doi.org/10.1097/jtn.0000000000000448

[3] Lilly, A., Cavella, M., Roper-Lewis, A., Weglarz, M., Ayala, L., Lilli, A. C., Greene, M., Colabelli, N. B., & Duggan, A. K. (2021). Improving outcomes for families of children with medical needs known to child welfare: a nurse care coordination program. Child Maltreatment, 27(2), 267–278. https://doi.org/10.1177/10775595211044496

[4] Matiz, L. A., Kostacos, C., Robbins-Milne, L., Chang, S. J., Rausch, J. C., & Tariq, A. (2021). Integrating Nurse Care Managers in the Medical Home of Children with Special Health Care needs to Improve their Care Coordination and Impact Health Care Utilization. Journal of Pediatric Nursing, 59, 32–36. https://doi.org/10.1016/j.pedn.2020.12.018

[5] Gall, V. N., Buchhalter, J., Antonelli, R. C., Richard, C., Yohemas, M., Lachuk, G., & Gibbard, W. B. (2022). Improving Care for Families and Children with Neurodevelopmental Disorders and Co-occurring Chronic Health Conditions Using a Care Coordination Intervention. Journal of Developmental and Behavioral Pediatrics, 43(8), 444–453. https://doi.org/10.1097/dbp.0000000000001102

[6] Slater, P. J. B., Hastings, Y., Nicholson, J., Noyes, M., Benitez, L., Pollock, K., Peacock, R., Cox, A., Gunning, R. D., Caris, K., Petersen, D., Henry, C., Spanner, R., Beckett, K., & Chisholm, C. (2022). Fifteen years of shared care for paediatric oncology, haematology and palliative patients across Queensland: The role of Regional Case Managers. Australian Journal of Rural Health, 31(3), 436–451. https://doi.org/10.1111/ajr.12958

[7] Love, L., Newmeyer, A., Ryan‐ Wenger, N., Noritz, G., & Skeens, M. A. (2022). “Lessons learned in the development of a nurse‐led family centered approach to developing a holistic comprehensive clinic and integrative holistic care plan for children with cerebral palsy.” Journal for Specialists in Pediatric Nursing, 27, e12354. https://doi.org/10.1111/jspn.12354

[8] Cohen, E., Quartarone, S., Orkin, J., Moretti, M. E., Emdin, A., Guttmann, A., Willan, A. R., Major, N., Lim, A., Diaz, S., Osqui, L., Soscia, J., Fu, L., Gandhi, S., Heath, A., & Fayed, N. (2023). Effectiveness of structured care coordination for children with medical complexity. JAMA Pediatrics, 177(5), 461. https://doi.org/10.1001/jamapediatrics.2023.0115

[9] Martins, A., Aldiss, S., Taylor, R., & Gibson, F. (2022). Care coordination, consistency and continuity: the case of the key worker role in children’s cancer care. International Journal of Qualitative Studies on Health and Well-being, 17(1). https://doi.org/10.1080/17482631.2022.2092958

[10] Mosquera RA, Avritscher EBC, Pedroza C, Bell CS, Samuels CL, Harris TS, Eapen JC, Yadav A, Poe M, Parlar-Chun RL, Berry J, Tyson JE. Hospital Consultation From Outpatient Clinicians for Medically Complex Children: A Randomized Clinical Trial. JAMA Pediatr. 2021 Jan 1;175(1):e205026. doi: 10.1001/jamapediatrics.2020.5026. Epub 2021 Jan 4. PMID: 33252671; PMCID: PMC7783544.

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.