Holistic Care Coordination

HCC Overview Video

Accessing community and health services can sometimes feel like putting a puzzle together. A puzzle that you do not know what it looks like, you do not know how many pieces you need to complete the puzzle, AND you have to go on a scavenger hunt to find them. Each piece of the puzzle is different, but critical to the overall picture.

Click on the video to the left to learn more.

Holistic Care Coordination (HCC)

What is Holistic Care Coordination (HCC)?

Ways of coordinating care have been referred to as many things: case management, targeted care management, service coordination, care coordination, and more.

Holistic Care Coordination (HCC) is an approach to coordinating the services, care, and supports a person might need. This is done in a holistic or "whole-person" manner. What makes HCC unique is that it is a patient- and family-centered approach that considers the person, their circumstances, and their medical, behavioral, educational, social, developmental, and financial needs. Most of those previous definitions only focus in on one of these aspects or components of a person's life. Engaging in this holistic manner recognizes that you can't silo, or separate, the person from their circumstances – and that their circumstances impact their health and well-being, educational and career outcomes, community inclusion and engagement, and overall life experiences.

This holistic approach is rooted in a deep belief that collaboration is essential to supporting patients and their families. When it comes to parenting, many adopt the adage, "It takes a village." This is also true with providing care coordination in a holistic manner. Recognizing that each organization, service provider, health or community system, and member of the family may hold a piece of the puzzle. Relationships between the individual/family served and all types of providers is critically important to support improved access and outcomes.

Click on the video to the right to learn more.

HCC Relationships Video

Kansas Initiatives to Expand Holistic Care Coordination

It is recognized that while care coordination is a critical component to providing care through a medical home, there are many other places where some form of care coordination can be received. In Kansas, this is widespread and the Kansas Department of Health and Environment is hoping to support alignment and partnership among these types of programs, to assure families are able to access the support they need, when they need it.

Primary Care Provider Pilot Project

This toolkit was developed as a way to increase knowledge and provide technical assistance to offices interested in providing holistic care coordination, or building a HCC program within their practice.

Throughout 2021, there will be several opportunities for providers to participate.

  • Spring 2021 – Provider Survey
    We gained valuable information on current knowledge, attitudes, and practices around holistic care coordination through a survey that closed May 31st. For more information contact Kaylee Goss at Kaylee.Goss@ks.gov.
  • Spring 2021 – A series of virtual roundtables were completed to discuss standards around care coordination and learn from providers what assistance or support could be valuable for their practice. Click here to access the roundtable presentations.
  • Summer 2021 – Short-Term Quality Improvement
    Short-term quality improvement activities (1-3 weeks) to gain insight and input on the toolkit contents and help practices begin to assess how care coordination could improve the quality of care their patients receive.
  • Fall 2021 – Long-Term Quality Improvement
    Long-term quality improvement activities (3-12 months) with targeted technical assistance for providers who want to establish HCC programs, or implement certain care coordination standards.

Related Kansas Initiatives or Programs


The Kansas Special Health Care Needs program offers holistic care coordination supports for children with special health care needs and their families that meet medical eligibility criteria. Learn more here.


Community Health Workers (CHW's) provide services and supports very similar to HCC. The CHW Coalition defined the role of the CHW and established core competencies for the workforce. The Steering Committee is working to establish sustainable reimbursement for CHW's in KS.

Service Care Coordination

Kansas participated in Phase 2 of the Pediatrics Supporting Parents (PSP) technical assistance project and conducted a review of service coordination under Medicaid Managed Care to produce key recommendations for improving access to care coordination for young children and their families.

Care Coordination at the National Level

Care coordination has been around for decades, and is often referred to under many different names. As the benefits from care coordination have been identified, it has gained popularity and is now considered an essential element of a medical home.

Patient-Centered Medical Home Joint Principles

The National Resource Center for Patient/Family-Centered Medical Home provides technical assistance and support to states interested in implementing the patient/family-centered medical home model, ultimately improving the health and well-being of patients they serve, and their families. As a key component to the medical home, the Center has some great resources around care coordination that mirror the goals of the HCC efforts in Kansas.

Fact Sheet

The Center for Medical Homes has developed a short fact sheet about care coordination. In it, you will find information on characteristics of care coordination, competencies needed to provide care coordination, and a few implementation activities.

  Medical Homes

Visit the Center for Medical Homes site on care coordination. They offer tools and resources for providing care coordination.

The National Academy for State Health Policy along with the Lucile Packard Foundation for Children's Health developed a set of standards that support high quality care coordination practice. Released in 2020, these Standards include key domains that are important considerations for all care coordination, not only children with special health care needs. This tool kit was developed with these standards.

National Care Coordination

Click on the puzzle to learn more
about the national standards.