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Service Coordination in Home Visiting

What is service coordination?

Service coordination is the “intentional organization of activities between two or more [entities] to facilitate, in partnership with the family, the delivery of the right services in the right setting at the right time.” [1]

Service coordination is a core element of most early childhood home visiting programs.

Examples of service coordination in home visiting:


Maria is a single mother of a two-year boy and a newborn baby girl. After her daughter was born, she began to experience symptoms of postpartum depression, but didn’t recognize them. Maria is enrolled in a home visiting program where Karen, the home visitor, visits weekly to discuss how she is doing and talk about her goals for herself and her children. Maria tells Karen that she doesn’t see her friends much anymore. Maria gets tearful when she talks about feeling alone. Karen notices that Maria has been more withdrawn, so she uses a depression screening tool, the Edinburgh Postpartum Depression Scale, and confirms her suspicion that Maria has symptoms of postpartum depression. Karen refers Maria to a counselor, but Maria is reluctant to go. After several conversations and lots of encouragement from Karen, Maria agrees to call the counselor. During one of the home visits, Karen sits with Maria while she makes the phone call. Karen follows up at each home visit with Maria to make sure she is receiving the services she needs.

As shown in this example, service coordination involves much more than simply giving a phone number to the family. Maria’s story demonstrates the key components of service coordination—assessment, screening, referral, linkage, and follow-up.


Erica, pregnant and on bedrest with her first child, recently enrolled in a rural home visiting program. Stephanie, her home visitor, is eager to help Erica prepare for her baby and suggests that they identify a short list of goals. Knowing that Erica has a car, Stephanie asks if she has a car seat. Erica admits that she does not, and is concerned about the expense as well as how to go about getting a car seat while she is on bedrest. Together, they agree that getting a car seat and having it properly installed would be two good short-term goals. Fortunately, Stephanie knows of a local organization that provides car seats for expectant mothers in need. Stephanie also gives Erica information about free safety checks at the police station. Erica agrees to call the organization and to arrange for her boyfriend to pick up the car seat and stop by the police station to have it installed. On her next visit, Erica proudly shows Stephanie the car seat mounted properly in the vehicle. Stephanie is happy to see that Erica completed her first goals and they discuss what her next goals will be.

Service coordination is most likely to be successful when families and home visitors work together to set goals that are attainable and that clearly incorporate family preferences. In this example, the home visitor leverages her vast knowledge of community resources. She also helps Erica identify informal supports to help her reach her goals while on bedrest.


Kira is a mom of three boys ages 7, 5, and 2 years. She was referred to a home visiting program by her pediatrician and has been meeting with her home visitor, Sherry, for the past few months. At a recent home visit Sherry administered the Ages and Stages Questionnaire (ASQ) with Diego, Kira’s youngest, and discovered possible signs of a speech delay. Sherry explained the results to Kira, and offered a referral to Early Intervention (Part C). Sherry gave Kira pertinent information, such as how to schedule an appointment, and shared that she has known many families who have worked with Early Intervention staff, with positive results. Sherry talks with Kira about early intervention and how it could help Diego. Kira seems skeptical, stating that neither of her older sons needed early intervention and that Diego is just a “late bloomer.” Sherry replies that she’s probably right, and asks if it would be alright if they both keep an eye on it and revisit the issue in a couple of weeks.

Over the next few visits Sherry shows Kira some games that she can play with Diego to encourage speech development. Kira and Diego seem to enjoy the games, and Sherry continues to monitor his development. After a few weeks, Sherry asks Kira if it would be alright if they do that portion of the Ages and Stages one more time, to see if the games are helping. This time Sherry explains the purpose of each activity, and Kira sees that there may be a delay. She agrees to schedule an appointment. Because Kira seems nervous, Sherry sits with her while she makes the call and offers to be present at the evaluation.

There are many reasons why parents may not be ready to accept a referral. In this example, Sherry respected the family’s preferences, offering support while patiently monitoring Diego’s progress. Service coordination requires that families have the information and support they need to make informed decisions. It also requires home visitors to have empathy, patience, and persistence as they support parents’ self-management of goals.

[1] Adapted from McDonald et al. Care Coordination Measures Atlas Update. AHRQ 2014.