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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Medical Home: Referrals.

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Strategy. Care Coordination and Case Management

Approach. Support providers in connecting patients with needed services across networks of care to improve access and communication among medical centers, community care, and social services

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Overview. Care coordination and case management improvements can connect patients to needed medical care, community care, and social services. Techniques such as checklists during WIC visits and discharge bundles have been reported as easy to use and improvements in completing various components of the bundle.[1,2] Patients with higher clinical needs had more follow-up visits with embedded child psychiatrists, with nearly 75% of referred children attending evaluations.[3] Patient navigators have been shown to lead to more successful referrals.[4,5]

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:

  • Referral tracking and follow-up data
  • Provider satisfaction surveys
  • Provider-to-provider communication records

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.
  • Timeliness of Care. This strategy promotes delivery of healthcare services in a timely manner to optimize benefits and prevent complications.
  • Patient Experience of Care. This study improves individuals' perceptions, feelings, and satisfaction with the healthcare services they receive.

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. Population/Systems-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 care team members trained in care coordination best practices. (Measures workforce capacity building for coordination)
  • Number of patients with complex needs assigned a dedicated care coordinator. (Assesses reach of care coordination services)

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

  • Percent of care coordination encounters involving shared care planning with patients and families. (Measures patient engagement in coordination process)
  • Percent of referrals adhering to standardized protocols for information exchange. (Assesses fidelity of care coordination practices)

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

  • Number of cross-sector partnerships established that results in seamless care coordination. (Measures collaborative infrastructure for coordination)
  • Percent of patients reporting feeling supported and informed through care coordination services. (Measures patient support through coordination)
  • Number of communities experiencing improved health outcomes through tailored coordination interventions. (Measures population health impact of coordination)
  • Number of successful coordination models adopted across multiple care settings. (Shows spread of effective coordination approaches)

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

  • Percent of cross-sector partnerships established that results in seamless care coordination. (Measures collaborative infrastructure for coordination)
  • Percent of patients reporting feeling supported and informed through care coordination services. (Measures patient support through coordination)
  • Percent of communities experiencing improved health outcomes through tailored coordination interventions. (Measures population health impact of coordination)
  • Percent of successful coordination models adopted across multiple care settings. (Shows spread of effective coordination approaches)

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] Farmer, J. E., Falk, L. W., Clark, M. J., Mayfield, W. A., & Green, K. K. (2022). Developmental Monitoring and Referral for Low-Income Children Served by WIC: Program Development and Implementation Outcomes. Maternal and child health journal, 26(2), 230–241. https://doi.org/10.1007/s10995-021-03319-9

[2] Farmer, J. E., Falk, L. W., Clark, M. J., Mayfield, W. A., & Green, K. K. (2022). Developmental Monitoring and Referral for Low-Income Children Served by WIC: Program Development and Implementation Outcomes. Maternal and child health journal, 26(2), 230–241. https://doi.org/10.1007/s10995-021-03319-9

[3] Spencer, A. E., Chiang, C., Plasencia, N., Biederman, J., Sun, Y., Gebara, C., MGH Chelsea HealthCare Center, Jellinek, M., Murphy, J. M., & Zima, B. T. (2019). Utilization of Child Psychiatry Consultation Embedded in Primary Care for an Urban, Latino Population. Journal of health care for the poor and underserved, 30(2), 637–652. https://doi.org/10.1353/hpu.2019.0047

[4] Messmer, E., Brochier, A., Joseph, M., Tripodis, Y., & Garg, A. (2020). Impact of an On-Site Versus Remote Patient Navigator on Pediatricians' Referrals and Families' Receipt of Resources for Unmet Social Needs. Journal of primary care & community health, 11, 2150132720924252. https://doi.org/10.1177/2150132720924252

[5] Sprecher, E., Conroy, K., Chan, J., Lakin, P. R., & Cox, J. (2018). Utilization of Patient Navigators in an Urban Academic Pediatric Primary Care Practice. Clinical pediatrics, 57(10), 1154–1160. https://doi.org/10.1177/0009922818759318

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.