Family Care Coordination Services


Family care coordination is a proven intervention which strives to facilitate a seamless delivery of services for mother and children through outreach, client assessment, care planning, education and counseling on health behavior risk reduction during both clinic and home visits with the family. Family Care Coordination incorporates the goals of prenatal care coordination -- early entrance into prenatal, reduced low birthweights in infants, and reduced infant mortality, etc.,-- and expands then to facilitate services of "at-risk" children, children with special health care needs, and their families. Goals are to improve utilization of EPSDT services, immunization service, primary care providers, and to empower families with education and support to access health, education, and social services they need. This will contribute to improved birthweights, infant mortality rate, child abuse rates, child health, and many of the Year 2000 Objectives and ISDH Public Health Priorities. Care coordinators also work closely with physicians (as liaison with the client) and community leaders to develop the health care system.

Maternal and Child Health Services (MCHS) participated in the development of family care coordination services in the state of Indiana through collaboration with other agencies and infrastructure building. MCHS has facilitated infrastructure building.MCHS has facilitated infrastructure building by:

  • participation in the Indiana collaboration Project Subcommittee on Care Coordination;
  • participation in the Indiana Healthy Families child abuse prevention program with initial collaborative funding and continuous participation in grant review
    and selection;

  • participation in the development of the prenatal Care Coordination Program reimbursed by Medicaid through funding the Indiana prototype, collaborating on the certification and training of care coordinators with the Indiana Chapter of the National Association of Social Workers, and assisting Medicaid staff in the development of the "Outcome Report From", the completion of which is
    required for final reimbursement;

  • the development and provision of the Community Health Worker certification training;

  • the facilitation of triennial, regional networking meetings for practicing care coordinators;

  • providing funding support to grantees interested in providing prenatal and family care coordination as well as local care coordination for Children's Special Health Care Services (CSHCS) enrolled children;

  • development of a Family Care Coordination Manual.


  • Care Coordination for CSHCS enrolled children is an option in the 1993 Rule promulgated for the CSHCS program. State personnel have been used for care coordination,to date.In an effort to provide more community-based, comprehensive care coordination and to make more manageable caseloads for the state care coordinators, the care coordination has been expanded through grants.

  • The Omnibus Reconciliation Act of 1989 and of 1990 includes as one of the four strategies to support women and children is home visiting for pregnant women and/or children.Home visiting services include care coordination/case management, risk assessment and reduction, and follow-up to clinical services. In Indiana, Medicaid has chosen to reimburse for prenatal care coordination, but at a rate which usually requires additional underwriting of staff. MCHS has underwritten grantees to provide this service, because the intervention has been proven successful in lowering infant mortality rates (an ISDH Public Health Priority). State MCHS staff has provided collaboration in training, planning, outcome evaluation, quality assurance effort, and infrastructure building with other state and local agencies.

  • Family Care Coordination for at-risk families was implemented to enable prenatal care coordinators to follow children through age one and ensure that children have preventive health care available. The OBRA legislations have an option for family care coordination to ensure Early Periodic Screening Diagnosis and Treatment program (EPSDT) utilization.Indiana Medicaid has not implemented reimbursement for that option.If outcomes for Family Care Coordination shows improvement in EPSDT rates, this may provide support for Medicaid reimbursement.

Contact : Nurse Consultant
Fax: (317)233-1300
Indiana State Department of Health