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Social Care Services Evidence Summary: Coordination Functions

This evidence summary includes a broad range of research/resources on coordination functions and is primarily focused on health 

care impact. It is not intended to be an exhaustive compilation of research/resources on this topic. The information presented in this 

summary can inform the value proposition of partnering with a community-based organization (CBO) or a network of CBOs to offer 

these services and supports as part of a strategy to address social determinants of health (SDOH).

Care coordination synchronizes the delivery of an individual’s health and social care from multiple providers to reduce 

fragmentation of care and support and to cohesively meet the individual’s support needs. Care coordination has been shown to 

reduce preventable hospital admissions, reduce costs for both the patient and health care system, and improve the quality of care 

for high-risk, high-cost individuals.1

Person-centered planning, like care coordination, is a function that prioritizes and focuses on the specific needs and preferences of 

each individual. Person-centered planning is a guided process for learning how someone wants to live at home, at work, or in the 

community and developing a plan to help make it happen2. Person-centered planning is a widely used, process-oriented approach 

that empowers the consumer to select and organize the services and supports that they may need to live in the community.3

While aging and disability networks across the nation vary in services and functions provided, care coordination and personcentered planning are widely adopted functions that are increasingly being used to shift to a more integrated, person-centered, and 

coordinated health and social care system.4

Research and resources related to care coordination and person-centered planning functions provided by aging and disability 

networks are included below.

1 https://www.rwjf.org/en/library/research/2014/02/engaging-patients-improves-health-and-health-care.html

2

https://ddsd.vermont.gov/person-centered-thinking

3 https://acl.gov/programs/consumer-control/person-centered-planning

4 https://academic.oup.com/ppar/article-abstract/29/2/67/5485004?redirectedFrom=fulltext
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Care Coordination Research

Study Population 

Studied

Objective of Study Type of Analysis Findings / Results

Amjad et al.

(2018)

303 communitydwelling adults 

70 years or older 

with a cognitive 

disorder in 

Baltimore, 

Maryland

To investigate the effects of 

a novel dementia care 

coordination program on 

health service utilization.

Single blind 

randomized 

control trial

Home and community-based service 

utilization significantly increased from 

baseline to 18 months in the 

intervention compared to the control. 

There was no impact on acute care and 

inpatient services, however.

Berkowitz et al.

(2018)

2,154 Medicare 

beneficiaries and 

2,532 Medicaid 

beneficiaries

To determine whether the 

Johns Hopkins Community 

Health Partnership (J-CHiP) 

was associated with 

improved health outcomes 

and lower spending.

Nonrandomized 

acute care 

intervention (ACI) 

and community 

intervention (CI)

For the CI group, there was a total cost 

of care reduction of $24.4 million and 

overall reduction in hospitalizations, 

emergency department visits, 30-day 

readmissions, and avoidable 

hospitalizations. For the ACI group, 

there was a total cost of care reduction 

of $29.2 million with decreases in 

hospitalization and practitioner follow 

up. 

Counsell et al.

(2007)

951 adults 65 

years or older 

with an annual 

income less than 

200% of the 

federal poverty 

limit

To test the effectiveness of 

the Geriatric Resources for 

Assessment and Care of 

Elders (GRACE) model on 

improving the quality of 

care for low-income seniors 

in primary care.

Randomized 

control trial

Significant improvement in general 

health, vitality, social functioning, and 

mental health in intervention patients 

compared to those receiving usual 

care. The cumulative 2-year emergency 

department visit rate was lower for 

intervention patients in the second 

year.

Counsell et al.

(2009)

951 low-income 

seniors aged 65 

years or older in 

To provide a cost analysis of 

the GRACE model 

Randomized 

control trial

For patients at high-risk of 

hospitalization, the GRACE model 
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Study Population 

Studied

Objective of Study Type of Analysis Findings / Results

community-based 

primary care 

health centers

intervention for the health 

care delivery system.

intervention is cost neutral from the 

healthcare delivery perspective.

Jack et al. (2016) This systematic 

analysis included 

2,941 studies; 34 

studies met the 

inclusion and 

methodological 

criteria.

To systematically review 

existing studies on the 

impact of community 

health workers on the use 

of healthcare services.

Systematic review The findings suggest that it is possible 

to achieve reductions in care utilization 

and cost savings by integrating 

community health workers into chronic 

care management, however, 

community health workers alone do 

not make interventions successful.

Leff et al. (2009) 49 physicians and 

904 of their 

chronically ill 

patients aged 65 

years or older

Evaluate the preliminary 

effects of the Guided Care 

model for care coordination 

on health service utilization 

and costs.

Clusterrandomized 

controlled trial

Patients that received the Guided Care 

model experienced fewer hospital 

days, skilled nursing facility days, 

emergency department visits, home 

healthcare episodes, and specialist 

visits than those that did not receive 

the care coordination model. Overall, 

the intervention resulted in decreased 

utilization and cost.

Nelson et al.

(2019)

152 children aged 

12 to 42 months 

old who receive 

well-child care at 

a community 

health center 

serving 

predominantly 

Hispanic families 

To test the efficacy of 

telephone-based 

developmental screening 

and care coordination 

through 2-1-1 Los Angeles 

County.

Intention-to-treat 

analyses

Significantly more children assigned to 

the intervention group were referred 

and were receiving services within 6 

months compared with children 

assigned to usual care alone.
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Study Population 

Studied

Objective of Study Type of Analysis Findings / Results

Rowe et al.

(2016)

Patients cared for 

by social workers

To examine the mean 

utilization of costly health 

care services for older adult 

patients after 

implementation of the 

Ambulatory Integration of 

the Medical and Social 

(AIMS) care coordination 

model.

Exploratory, 

retrospective 

evaluation

Patients who received the intervention 

had a lower mean utilization of 30-day 

hospital readmissions and emergency 

department visits than the general 

patient population.
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Care Coordination Resources

Resource Author Description of Content Target Audience

Code of Federal Regulations This government webpage outlines 

general requirements for health care 

quality and lists a number of activity 

requirements to improve health care 

quality, touching on factors like activity 

design, programs to prevent hospital 

readmission, implementation of health 

care activities, and activity expenditures.

Any organization interested in federal 

guidelines and regulations as they plan 

and implement health care related 

activities.

Rowe, et al. (2016) This article explains the four different 

areas critical to the health and well-being 

of older adults who require further 

advancement (enhancing care delivery 

for chronic conditions, strengthening the 

elder care workforce, fostering 

engagement in late life, and advanced 

illness and end-of-life care).

General audience, any individual or 

organization interested in learning more 

about the different facets of older adult 

care and how the field is expanding.

National Quality Forum (2017) This technical report provides an in-depth 

review of performance measures for care 

coordination conditions.

General audience, appropriate for anyone 

interested in a detailed review of 

National Quality Forum’s care 

coordination portfolio.

The Commonwealth Fund (2016) This report provides an overview of the 

Guided Care model and shares the results 

of a number of studies that test the 

effectiveness of the model.

General audience, anyone interested in 

learning about the program features and 

effectiveness of this particular care 

coordination model.
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Person-Centered Planning Research

Study Population Studied Objective of Study Type of Analysis Findings / Results

Gosse et al. (2017) Persons receiving an 

individualized 

planning process and

the traditional 

planning process

This study compares 

traditional planning to 

individualized planning 

on supports obtained 

and personal objectives 

accomplished using a 

randomized between‐

group design.

Randomized betweengroup design; when the 

traditional planning 

group subsequently 

received individualized 

planning, they 

replicated the results of 

the first individualized 

planning group.

Persons receiving an 

individualized planning 

process improved in both 

supports and personal 

outcomes as compared to 

the traditional planning 

group. When the traditional 

planning group 

subsequently received 

individualized planning, 

they replicated the results 

of the first individualized 

planning group. The 

findings support 

implementation of an 

individualized planning 

approach in service 

agencies for individuals

with ID.

Ha & Park (2020) The study 

participants included 

40 communitydwelling older adults 

aged 65 years or 

older living in South 

Korea.

To examine the effects 

of a person-centered 

nursing intervention 

program for frailty 

(PNIF) in older adults.

Quasi-experimental 

pretest–posttest design

The findings showed that 

the group that received the 

person-centered 

intervention had 

significantly improved 

frailty, physical function, 

grip strength, depression, 

and nutritional status 

compared to those that did 
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Study Population Studied Objective of Study Type of Analysis Findings / Results

not receive the 

intervention. 

Hughes (2013) 6 case managers and 

social workers that 

implement the 

person-centered 

planning model with 

individuals with 

intellectual or 

developments 

disabilities (I/DD) in 

Minnesota

Research the benefits 

and barriers to 

implementing the 

person-centered 

planning model for 

adults with I/DD and 

other populations as 

applicable. 

Qualitative exploratory 

design

Person-centered planning

allows for increased selfdetermination, allows for 

the individual receiving care 

to have choice in their living 

arrangements, work, and 

how they spend their free 

time. Challenges to 

planning and implementing 

person-centered planning

include limited time, 

funding, and resources. 

Hughes (2013) Experts who are 

implementing the 

person-centered 

planning model

The purpose of this 

study was to explore 

the benefits and 

barriers to 

implementing PersonCentered Planning as a 

replacement for, or in 

addition to traditional 

service planning for 

adults with 

developmental 

disabilities.

A qualitative 

exploratory design was 

used to hear from the 

voices of people who 

have first-hand 

knowledge and 

experience with using 

person centered 

planning for individuals 

with I/DD.

The strongest theme that 

emerged from this study is 

that person-centered 

planning is individualized 

planning that puts the client 

into the role of expert over 

his or her life. This expert 

role allows for increased 

self-determination because 

it increases choices in areas 

such as types of living 

arrangements, type of 

employment, and leisure 

activities. The circle of 

support may be the most 

important component of 
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Study Population Studied Objective of Study Type of Analysis Findings / Results

helping the focus person 

achieve their future vision.

Kaehne & Beyer

(2013)

44 individuals with 

disabilities in the 

United Kingdom 

To review the efficacy 

of person-centered 

planning as part of 

school transition.

Documentary analysis The data shows an increase 

in the participation of 

young people at review 

meetings and a significant 

shift in topics discussed 

during the transition 

planning process compared 

with previous programs.

Menchetti (2003) 83 supported 

employees 

This study examined 

effects of personcentered planning on 

career choice and 

employment outcomes 

attained by supported 

employees.

Choice was measured 

by analyzing degree of 

match between 

employees' career 

preferences and their 

current employment.

High and moderate levels of 

preference match were 

attained by 72 (83%) of 

employees studied. Wages 

and length of employment 

did not differ significantly 

by level of match. These 

employment outcomes 

tended to favor employees 

in high and moderate 

match groups, however. 

Implementation and 

evaluation issues related to 

person-centered planning 

were further examined 

through a focus group of 

service providers. 

Responses identified 

measuring effectiveness of 

person-centered planning, 
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Study Population Studied Objective of Study Type of Analysis Findings / Results

supporting training and 

commitment of service 

providers, collaborative 

problem solving, and 

continuous process 

improvement as issues 

requiring further research.

Oregon Department 

of Human Services

(2018)

Oregon Aging and 

Disability Resource 

Centers (ADRCs)

To make the business 

case that the benefits 

of ADRC services, 

including options 

counseling/personcentered counseling,

exceed the cost to run 

ADRC programs.

Social return on 

investment

The analysis concluded that 

there is a strong business 

case for Oregon’s ADRCs. 

The estimated social return 

on investment of the ADRCs 

in Oregon is 11.1 to 1. The 

benefits in Oregon totaled 

$39.8 million at a cost of 

$3.6 million in 2016-2017.

Poey et al. (2017) The study 

participants included 

6,214 nursing home 

residents in 2013-

2014 and 5,538 

nursing home 

residents in 2014-

2015 in Kansas.

To examine if personcentered practices 

promote satisfaction, 

quality of life, quality of 

care, and services 

among nursing home 

residents.

Longitudinal, 

retrospective cohort 

study using an in-person 

survey

The results of the study 

showed that after 

controlling for facility 

characteristics, patients’ 

satisfaction with quality of 

life and quality of care was 

higher in nursing homes 

that implemented personcentered practices than 

those that did not.

Reid et al. (1999) The study 

participants were 

four individuals with 

To evaluate the degree 

to which items and 

activities reported to 

A sample of the 

reported preferences of 

the participants was 

The results of the study 

showed that individuals 

may want or require more 
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Study Population Studied Objective of Study Type of Analysis Findings / Results

profound and 

multiple disabilities.

be preferred in personcentered plans 

represented accurate 

preferences based on 

how individuals 

responded when 

presented with the 

items and activities.

systematically assessed 

by observing each 

participant’s approach 

and avoidance 

responses to the items 

and activities.

than what is outlined in 

their person-centered care 

plan.

Stanhope et al. (2013) 10 community mental 

health centers 

randomly assigned to 

receive training in 

person-centered 

planning and 

collaborative 

documentation or 

provide usual 

treatment

Examine the impact of 

person-centered 

planning and 

collaborative 

documentation on 

service engagement 

and medication 

adherence within 

community mental 

health centers 

(CMHCs).

Randomized control 

trial

Person-centered planning 

and collaborative 

documentation were 

associated with significantly 

greater engagement in 

services and higher rates of 

medication adherence.

Yasuda & Sakakibara

(2016)

The study 

participants included 

40 care staff 

members at a 

geriatric nursing 

home.

To assess the effects of 

care staff training 

based on personcentered care and 

dementia care 

mapping on the quality 

of life (QOL) of 

residents with 

dementia in a nursing 

home.

The effects of the staff 

training on the QOL of 

residents with dementia 

were evaluated three 

times at roughly onemonth intervals 

(baseline, preintervention, and postintervention).

The results of the study 

showed that the personcentered care training 

intervention improved the 

overall well-being of the 

geriatric nursing home 

residents. The findings of 

the study support the 

effectiveness of personcentered care and suggest 

that nursing home staff 
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Study Population Studied Objective of Study Type of Analysis Findings / Results

should be trained in personcentered practices. 

Zimmerman et al.

(2015)

Eight residents and 

staff participated in 

cognitive testing, and 

228 residents and 123 

staff participated in 

field testing

Develop selfadministered 

questionnaires of 

person-centeredness 

for completion by 

residents and staff in 

assisted living (AL), in 

response to concerns 

that AL is not personcentered; also, 

demonstrated personcenteredness is 

necessary for Medicaid 

support as a home- and 

community-based 

services provider.

Community-based 

participatory research 

partnership among a 

research team, a 

consortium of 11 

stakeholder 

organizations, and 

others; methods 

included literature 

review, item generation 

and reduction, cognitive 

testing, field testing, 

exploratory factor 

analysis, and 

convergent and 

discriminant validity 

testing.

The final resident 

questionnaire included 49 

items and 4 factors: wellbeing and belonging, 

individualized care and 

services, social 

connectedness, and 

atmosphere. The staff 

questionnaire included 62 

items and 5 factors: 

workforce practices, social 

connectedness, 

individualized care and 

services, atmosphere, and 

caregiver-resident 

relationships. Staff scored 

person-centeredness higher 

than did residents, 

reflecting their different 

perspectives.
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Person Centered Planning Resources

Resource Author Description of Content Target Audience

J.E. Taylor & J.A. Taylor (2013) This article examines the historical development 

and evidence base, as well as the current 

challenges and potential of person-centered 

planning for adults with I/DD.

Researchers and various practitioners interested in 

the evolution and data behind person-centered 

planning and how it may be effectively used for 

adults with intellectual disabilities.

Robert Wood Johnson 

Foundation (2014)

This issue brief outlines the importance of personcentered planning and provides an overview of 

various initiatives and frameworks used across the 

country that help health systems better engage 

patients in their health.

Health plans and systems interested in testing or 

adopting a potential framework or initiative to 

improve person-centered care in their system.

The SCAN Foundation (2016) This issue brief details the effectiveness of personcentered programs in improving the care and 

quality of life of patients while also reducing 

medical expenditures and provides information on 

compensation methods and the return on 

investment.

Health plans and systems interested in 

understanding the cost benefit of implementing 

person-centered practice programs.