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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Medical Home: Overall.

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Strategy. Dedicated Care Coordinators

Approach. Use dedicated care coordinators to develop relationships with families to increase timely attendance of well-child visits and respond to the needs of families

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Overview. Research shows that designating a care coordinator with protected time to make outreach calls and identify patient needs are effective strategies for improving connections to the medical home. The care coordinator can identify and coordinate care with patients through establishing early relationships by making “welcome calls” to families which include congratulating them on the baby, welcoming them to the practice, reminding them of their appointments, and acting as the point-of-contact for caregiver’s concerns. The care coordinator can also serve as a critical component in connecting and referring families to needed services for community organizations outside of the provider’s office.[1] Alternatively, the care coordinator role can also be part of a home visiting program (see strategies for Strengthening Service Coordination Between Home Visitors and Pediatric Primary Care Providers). A recent study found that embedded care coordinators can significantly enhance the quality, efficiency, and responsiveness of care for children with medical complexity.[2]

Evidence. Emerging Evidence. Strategies with this rating typically trend positive and have good potential to work...

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 activity logs
  • Family needs assessment, referral data, and connection data
  • Family feedback and satisfaction data

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.
  • 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. Access descriptions of ESMs that use this strategy or aligned components.

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 primary care practices implementing dedicated care coordinator positions. (Assesses adoption of strategy)
  • Number of care coordinators trained in family-centered outreach and coordination techniques. (Measures workforce development)

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

  • Percent of care coordinators with protected time specifically allocated for outreach and coordination activities. (Ensures dedicated focus on role)
  • Percent of families receiving personalized care plans developed in collaboration with care coordinators. (Assesses individualized approach)

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

  • Number of partnerships established between care coordinators and community organizations. (Shows collaborative approach)
  • Number of quality improvement initiatives implemented based on care coordinator insights. (Assesses data-driven practice enhancement)
  • Number of missed appointments prevented through care coordinator outreach and reminders. (Quantifies impact on continuity of care)
  • Number of families showing improved health outcomes correlated with enhanced medical home connection. (Measures broader health impact)

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

  • Percent of care coordination resources allocated to engaging families experiencing challenges to consistent medical home access. (Measures resource distribution)
  • Percent of care coordinators trained in trauma-informed care practices. (Assesses preparation for serving populations)
  • Percent reduction in gaps in well-child visit attendance between different patient populations. (Measures improvements in health access)
  • Percent increase in early intervention rates for health issues among groups disproportionately affected by delayed care. (Evaluates impact on populations facing health challenges)

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] Brown, C. M., Perkins, J., Blust, A., & Kahn, R. (2015). A neighborhood-based approach to population health in the pediatric medical home. Journal of Community Health, 40(1), 1-11.
[2] 2 Munn, E. E., Griffin, J. W., Ramly, E., Ciccarelli, M. R., & Pangelinan, M. M. (2025). Clinicians' perspectives of a care coordination model for children with medical complexity. Frontiers in pediatrics, 13, 1626439.

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.