Care Coordination Initiative


The concept of Care Coordination for the MCAN sites was defined as— 

"a client-centered, assessment-based interdisciplinary approach to integrating heath care and social support services in which an individual's needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored by a care coordinator following evidence-based standards of care."

— From The Promise of Care Coordination a report commissioned by the National Coalition on Care Coordination.


The four Care Coordination program sites participated in a cross-site evaluation led by the Center for Managing Chronic Disease at the University of Michigan to assess outcome and process measures focused on care coordination and clinical outcomes.  The following surveys were the sources for quantitative cross-site data, and were administered at baseline and 12 months:

  1. Baseline Caregiver Survey English and Spanish
  2. 12 month Follow-up Caregiver Survey English and Spanish

The Manual of Operations (Baseline, Follow-up) details administration of the surveys.



Preliminary findings from this initiative across four program sites indicate that the percent of participants with “not well controlled” asthma decreased from 49 percent at baseline to 18 percent at 12 month follow-up.   


To learn more about care coordination, view these webinars:

Read more about the Care Coordination Initiative in the MCAN 10-Year Impact Report.