Skip Navigation

Strengthen the Evidence for Maternal and Child Health Programs

Sign up for MCHalert eNewsletter

Evidence Tools
MCHbest. Medical Home: Personal Doctor or Nurse.

MCHbest Logo

Strategy. Care Coordination and Case Management

Approach. Implement care coordination and case management programs to ensure children receive comprehensive and continuous care

Return to main MCHbest page >>

Overview. Effective care coordination is essential to providing high quality, timely healthcare, especially for children and youth with special healthcare needs. (CYSHCN) and children with medical complexity[1]. Oftentimes there is insufficient personnel to coordinate care and communication between primary care providers and specialists is limited. Strategies to improve care coordination include integrating nurse care managers to enhance care delivery models in pediatric medical homes,[2] using advanced practice registered nurses to deliver telehealth care coordination,[3] constructing care support teams to deliver shared plans of care,[4] and using shared care systems to facilitate better communication between primary care providers and specialists.[1] Evidence suggests that care coordination and case management are effective ways to ensure access to a comprehensive array of healthcare services for CYSHCN and children with medical complexity.

Evidence. Moderate Evidence. Strategies with this rating are likely to work. These strategies have been tested more than once and results trend positive overall; however, further research is needed to confirm effects, especially with multiple population groups. These strategies also trend positive in combination with other strategies. (Clarifying Note: The WWFH database calls this "some evidence").

Access the peer-reviewed evidence through the MCH Digital Library or related evidence source. (Read more about understanding evidence ratings).

Source. Peer-Reviewed Literature

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. Individual/Family-Focused

Examples from the Field. There are currently no ESMs that use this strategy. As Title V agencies begin to incorporate this strategy into ESMs, examples will be available here. Until then, you can search for ESMs that have similar intervention components in the ESM database.

Sample ESMs. Here are sample ESMs to use as models for your own measures using the Results-Based Accountability framework (for suggestions on how to develop programs to support this strategy, see The Role of Title V in Adapting Strategies).

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

PROCESS MEASURES:

  • Number of care coordination and case management programs established to serve children and families in a given community or population. (Measures availability and reach of care coordination services)
  • Number of care coordinators and case managers hired, trained, and supported to provide comprehensive and family-centered care planning and service coordination. (Shows workforce capacity and readiness)

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

PROCESS MEASURES:

  • Percent of care coordinators and case managers who demonstrate competence in developing individualized care plans, facilitating cross-sector communication, and supporting children's needs across health and social service systems. (Assesses workforce competency and effectiveness)
  • Percent of children and families who are engaged as active partners in developing, implementing, and monitoring their care coordination and case management plans. (Shows family engagement and shared decision-making)

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

PROCESS MEASURES:

  • Number of families who report high levels of satisfaction, trust, and partnership with their care coordinators and case managers in supporting their children's health and well-being. (Shows family experience and relationship quality)
  • Number of families who report increased knowledge, skills, and confidence in navigating the healthcare system and supporting their children's needs with the support of care coordinators and case managers. (Shows impact on family support and care management capacity)

OUTCOME MEASURES:

  • Number of communities that demonstrate improved child health outcomes and enhanced family well-being through the implementation of robust care coordination and case management systems. (Measures population health impact)
  • Number of healthcare organizations and systems that integrate care coordination and case management best practices and lessons learned into their standard operations, training, and performance improvement efforts. (Assesses organizational adoption and institutionalization)

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

PROCESS MEASURES:

  • Percent of families who report high levels of satisfaction, trust, and partnership with their care coordinators and case managers in supporting their children's health and well-being. (Shows family experience and relationship quality)
  • Percent of families who report increased knowledge, skills, and confidence in navigating the healthcare system and supporting their children's needs with the support of care coordinators and case managers. (Shows impact on family support and care management capacity)

OUTCOME MEASURES:

  • Percent of communities that demonstrate improved child health outcomes and enhanced family well-being through the implementation of robust care coordination and case management systems. (Measures population health impact)
  • Percent of healthcare organizations and systems that integrate care coordination and case management best practices and lessons learned into their standard operations, training, and performance improvement efforts. (Assesses organizational adoption and institutionalization)

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] Rea, C. J., Wenren, L. M., Tran, K. D., Zwemer, E., Mallon, D., Bernson-Leung, M., Samuels, R. C., & Toomey, S. L. (2018). Shared Care: Using an Electronic Consult Form to Facilitate Primary Care Provider-Specialty Care Coordination. Academic pediatrics, 18(7), 797–804.

[2] 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.

[3] Looman, W. S., Hullsiek, R. L., Pryor, L., Mathiason, M. A., & Finkelstein, S. M. (2018). Health-Related Quality of Life Outcomes of a Telehealth Care Coordination Intervention for Children With Medical Complexity: A Randomized Controlled Trial. Journal of pediatric health care : official publication of National Association of Pediatric Nurse Associates & Practitioners, 32(1), 63–75. [4] 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.

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.