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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Medical Home: Usual Source of Sick Care.

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Strategy. Care Coordination

Approach. Implement care coordination strategies within the provider-patient relationship

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Overview. Care coordination is the communication and collaboration that improves quality of care, reduces the need for urgent visits and allows care to be coordinated around each child.[1] Effective coordination is valuable for children who have chronic or ongoing conditions.[1] An essential characteristic of care coordination is that it is family-centered and team-based, and has well-defined goals, infrastructure and responsibilities.[2] Evidence suggests that effective care coordination can positively impact care of children with and without medical complexity.[3]

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 fidelity data
  • Provider-to-provider communication records
  • Family satisfaction surveys

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.
  • Timeliness of Care. This strategy promotes delivery of healthcare services in a timely manner to optimize benefits and prevent complications.
  • Quality of Care. This strategy promotes the degree to which healthcare services meet established standards aimed at achieving optimal health outcomes.

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. Individual/Family-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 teams trained in care coordination best practices and protocols. (Measures workforce development for care coordination)
  • Number of patients assigned a designated care coordinator to facilitate care planning and service integration. (Assesses implementation of care coordination)

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

  • Percent of patient encounters including comprehensive care coordination activities (e.g., needs assessment, care plan development). (Measures adherence to care coordination process)
  • Percent of providers consistently using evidence-based care coordination tools and systems. (Assesses provider adoption of care coordination practices)

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

  • Number of patients reporting high levels of satisfaction with care team support as a result of care coordination. (Measures patient-reported impact of care coordination)
  • Number of cross-sector partnerships established to integrate care coordination with other health and social services who report high levels of engagement. (Measures care integration efforts)
  • Number of healthcare organizations demonstrating improved patient outcomes through comprehensive care coordination strategies. (Measures organizational impact of care coordination)
  • Number of communities experiencing reductions in care fragmentation through effective care coordination models. (Assesses population health impact)

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

  • Percent of patients reporting high levels of satisfaction with care team support as a result of care coordination. (Measures patient-reported impact of care coordination)
  • Percent of cross-sector partnerships established to integrate care coordination with other health and social services who report high levels of engagement. (Measures care integration efforts)
  • Percent of healthcare organizations demonstrating improved patient outcomes through comprehensive care coordination strategies. (Measures organizational impact of care coordination)
  • Percent of communities experiencing reductions in care fragmentation through effective care coordination models. (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] Moreno MA. Pediatric Care Coordination. JAMA Pediatr. 2019;173(1):112. doi:10.1001/jamapediatrics.2018.4112

[2] Schor EL. Ten Essential Characteristics of Care Coordination. JAMA Pediatr. 2019;173(1):5. doi:10.1001/jamapediatrics.2018.3107

[3] de Banate MA, Maypole J, Sadof M. Care coordination for children with medical complexity. Curr Opin Pediatr. 2019 Aug;31(4):575-582. doi: 10.1097/MOP.0000000000000793. PMID: 31290774.

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.