Improving Care Coordination, Case Management, and Linkages to Service for Young Children: Opportunities for States

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As pediatric primary health care providers increase appropriate developmental screening and early identification of developmental delays in young children, the weak linkages among providers of services to children and families become increasingly apparent. Young children often fall through the cracks between pediatric primary health care providers and providers of mental health, early intervention, child welfare, and early care and education services.

Currently, there is a call for better linkages that support families in securing appropriate care and services. Five major types of barriers limit these linkages:

  • Constraints on primary care provider capacity to refer to and link to other community resources;
  • Inadequate service capacity for early childhood developmental and mental health services;
  • Gaps between programs and service delivery systems, including eligibility criteria;
  • Insufficient payment/financing for time spent in referral and coordination efforts; and
  • Different practice cultures and customs.

States can play an important role in removing barriers and providing support as communities move toward more integrated services. Federal programs can support state efforts to improve linkages. Medicaid, through its Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program; Children's Health Insurance Programs (CHIP); Title V Maternal and Child Health and Children with Special Health Care Needs programs; and programs implemented under the Individuals with Disabilities Act (IDEA), especially Part C Early Intervention Programs, provide a way to finance care coordination/case management (CC/CM) for health and related services.

Strategies to improve CC/CM and strengthen linkages include primary care practice-based strategies, service provider linkage strategies, and systems change and cross-system strategies. This report uses a framework that illustrates the intersection between these three levels and the various roles states can play to facilitate and support CC/CM and linkages as illustrated in Table 1.

States can review existing policies of key programs to identify barriers and opportunities for improvement. In particular, review of case management/care coordination rules and payments is critical. This paper provides key questions for reviewing state policies and financing strategies that support cross-system linkages and care coordination/case management (C/CM). Areas for action within each of the state's fiscal and administrative support roles are provided.


Table 1: Linkage and CC/CM Strategies to Promote Coordination Between Medical Providers and Community Referral and Resource Agencies

  Primary care practice-based strategies Services provider linkage strategies Systems change and cross- system strategies
Role of State Fiscal and Administrative Support Strategies that transform the way pediatric primary care practices are organized to deliver care Strategies that strengthen relationships between pediatric primary care and other providers Strategies that enhance or transform operations between health and other service systems at state level
Support for strategies that maximize use of personnel in linkages and CC/CM
  • Medical homes that use care planning and care coordination approaches.
  • Staff assigned to assure referrals and linkages, including onsite care coordinators.
  • Community-based staff that assist providers and families in completing referrals and linkages.
  • Co-location of primary health care and other services providers (e.g., child development, social work, mental health).
  • Resource and referral strategies to help medical providers and families learn about/link to resources, including parent-to-parent approaches.
  • Care coordination utilities that operate across a state (e.g., EPSDT coordinators statewide, coordination networks.
  • New structures to organize CC/CM personnel and programs (e.g., public health nurses, community social workers, MCO staff, CSHCN coordinators).
  • Health and mental health consultants in early care and education programs who provide referral and linkages to other providers.
Support for quality improvement initiatives and other mechanisms for assuring and monitoring quality
  • Quality improvement efforts within clinical practice settings which can address gaps in knowledge and behavior (e.g., introduce new tools, quality measurement).
  • Quality improvement initiatives that engage networks of providers in measuring and changing performance
  • Monitor and provide incentives for quality of care coordination, including completion of referrals care plans, etc.
  • Shared or common standards, definitions, and protocols across systems (e.g., common referral forms, shared definitions of special needs or special risks).
  • Public–private payer quality initiatives.
  • Cross-system professional training.
Support for data, information, and technology that facilitates linkages and communication among families and providers
  • Adoption of technology such as electronic medical records that facilitate linkages and CC/CM
  • Practice-based follow-up systems (e.g., practice registries, tracking systems).
  • Data, information, and technology strategies that support linkages (e.g., common referral forms, telephone consultation, telemedicine).
  • Electronic medical/health records that support patient-centered care.
  • Macro data and information strategies (e.g., surveys, early childhood information systems, shared resource data bases) that guide planning for early childhood health and related services.
  • Strategies to reduce administrative barriers for sharing information.
Support for individualized care plans and cross-systems planning
  • Individualized care plans used by primary care providers/medical homes.
  • Care plans that incorporate multiple provider perspectives and recommendations.
  • Part C Individualized Family Service Plans (IFSP) that link to pediatric primary care providers.
  • Planning for improved integration of early childhood services and systems with support for local implementation (e.g., early childhood comprehensive systems initiatives).


Areas for State Action:

Support for strategies that maximize use of personnel in assuring effective linkages and CC/CM. For example:

  • Financial incentives and supports for medical home providers that use care planning and CC/CM approaches (e.g., enhanced reimbursement for certified primary care providers).
  • Financing for care coordinators and other co-located professionals in primary care settings (e.g., direct or indirect reimbursement for primary care settings that add capacity through co-location).
  • Financing for care coordinating utilities such as EPSDT coordinators in every county.
  • Support for information or service centers designed to improve linkages and CC/CM.

Support for quality improvement initiatives and other mechanisms for assuring and monitoring quality related to referrals, linkages, and CC/CM. For example:

  • Incentives for quality improvement in clinical practices and among networks of providers.
  • Structures for monitoring and reporting quality of referrals and CC/CM.
  • Interagency agreements supporting common standards, definitions, and protocols across programs and providers.

Support for data, information, and technology that facilitates linkages and communication among families and providers. For example:

  • Financing and other incentives for electronic health records for children.
  • Structured referral processes, forms, and accountability.
  • Integrated child information and data systems that provide information for use by families and providers.
  • Interagency agreements designed to reduce barriers to information sharing among providers and systems.

Support for individualized care plans and cross systems planning. For example:

  • Incentives and supports for individualized, Patient-centered care plans in primary care/medical homes.
  • Review and reorganization of existing CC/CM programs, using a tiered approach to maximize available staff capacity (e.g., from community health workers to advanced practice nurses).
  • Structures that maximize the impact of Individualized Family Service Plans through systematic involvement of pediatric primary care providers, specialty care providers, child welfare programs, early intervention programs, and other services.
  • Early Childhood Comprehensive System plans that include explicit strategies to link health and public health and other services and supports.

The Assuring Better Child Health and Development (ABCD) initiative intends to focus state attention on improving CC/CM and linkages that can improve child development as the result of screenings. With this report, NASHP provides a foundation for a third ABCD Consortium that will help state agencies, especially Medicaid agencies, build and strengthen systemic linkages between pediatric primary health care providers and other child and family service providers to promote and support the healthy development of young children.