Coordination in Human Services: A Qualitative Inquiry

Background & Purpose: Clients served by public systems often have complex needs that span multiple service delivery systems. Social workers are encouraged to “coordinate” with one another to overcome fragmentation within service delivery systems. Unfortunately, the empirical evidence linking coordination strategies to improved client outcomes is inconclusive.

There has been considerable work on theoretical models of coordination and evaluation of its impact on systems and clients. However this literature is inconsistent in the conceptualization and measurement of “coordination,” and has not produced evidence that “coordination” has a direct positive impact on individual client outcomes. Without conceptual clarity and consistency, it is impossible to build a body of evidence in this area.

This study explores the meaning of “coordination” and the factors that facilitate or prevent coordination. The purpose is to promote conceptual clarity. In addition, suggestions are made to refine the theory, sharpen the focus of research, and pinpoint system interventions designed to improve the delivery of publicly funded services.

Methods: Definitions, indicators, examples, perceptions, and mental models of service coordination were explored from the perspectives of social workers and professional organizations that set standards and protocols for practice. First, interviews with social workers were conducted to explore the meaning of coordination, factors that facilitate or prevent coordination within human service delivery systems, as well as to identify potential indicators of coordination activity. Second, treatment guidelines archived by the National Guideline Clearinghouse were identified that included recommendations for coordination intended for use by social workers.

Using traditional content analysis and a grounded theory approach, major themes in interview transcripts and guideline texts were coded in NVivo. Analysis of the codes was anchored in a grounded theory approach to uncover meaning by allowing concepts and theories to emerge from the data (Bernard & Ryan, 2000; Strauss & Corbin, 1998). Relationships among the concepts were refined into a working theory and a causal loop diagram was constructed using principles of system dynamics (Sterman, 2000).

Results: Social workers characterize coordination as multiple providers working together with the same client in a manner that is consistent and continuous. Several potential strategies of delivering coordinated care were described in the treatment guidelines including integration, wrap-around and case management services. Factors that facilitate or prevent coordination emerged from the interview and guideline data including 1) complex client needs, 2) personal relationships with other providers, 3) information sharing, 4) client referrals, 5) power, 6) funding, 7) congruent treatment philosophies, and 8) time demands. These data indicated that service coordination impacts system-level outcomes related to continuity, comprehensiveness, and quality of care, and ultimately an improvement in client-level outcomes.

Conclusions: Service coordination is complex and varies by setting. The need for service coordination is driven by severe and complex client needs, but providers' relationships with one another (and the information and referrals exchanged to facilitate comprehensive and continuous care) drive the actual process. Standardization and formalization of roles, expectations, referral processes, agreements and treatment philosophies are potential strategies to facilitate coordination among providers.