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Curriculum Highlights

Service Coordination


Participants will be able to demonstrate their knowledge of the service coordination system and what services may be available.

Why This Topic is Important

Service coordination has evolved into a very important part of the service system. At one time, people with disabilities and/or their families had to “manage” the system on their own. It was up to them to figure out what they needed, who might provide it, if they qualified, and so on. Once they became a client of a particular agency, they might receive some help with coordinating the different services. In too many cases, however, they were simply added to the “caseload” of the “case manager”—an individual and/or a family became a “case to be managed.”

The intent of service coordination has always been relatively straightforward: help people identify and get what they need, coordinate the activities of the services and resources they get, and make sure service providers and others do what they're supposed to do. The intent is not to “manage” people as “cases.” Case management should have evolved into service coordination by now. But some states and/or agencies have been slow to make the change, both philosophically and in practice.

Partners participants should compare the concept of service coordination to what really happens. Think about what is being provided. Think about how well it's being done. Decide what to do to make it BETTER!

High quality service coordination is the hub of service provision. Service coordinators should be very knowledgeable about their roles, and about the needs of the people they serve. Training for service coordinators should be on-going. Service coordinators must have the authority to secure needed services. The number of people that a service coordinator is assigned to support should be small enough that he/she has the time to know each person/family well and be a rock-solid advocate for each.

Concept Highlights

Service coordinators need to:

  • Coordinate services, instead of managing cases.
  • Recognize the individuality and potential of the individuals/families they serve.
  • Support the power of the individual/family to get what they need, and not be a bureaucratic barrier.
  • Provide assistance for individuals/families to gain access to social, medical, educational, and other needed services.
  • Be knowledgeable, and continue to enhance their knowledge-base.
  • Be strong advocates on behalf of the people they serve.
  • Ask for, value, and respect the wants, needs, and opinions of the individuals/families they serve.
  • Ensure the implementation of program plans, and evaluate how well they do what they’re supposed to do.
  • Be assigned only the number of individuals/families they can serve well; service coordination fails when service coordinators are stretched too thin.

It’s possible for people with disabilities and/or their families to be their own service coordinators, with or without support to do so. The service coordination system and the individual/family should be working together to ensure inclusion, choice, participation, integration, and quality of life.


Service coordination is the formal link between the individual with a disability/family and the service system. When a plan is written for an individual/family, the service coordinator may play an active role in getting the service system to respond. In more regulated and formal systems, the plan may be seen as a piece of information that the system takes into account, but it may not take the place of the forms and processes required by law. Thus, the service coordinator’s role may need to ensure the plan makes it through the bureaucratic red tape.

The goal of service coordination should be to improve the quality of life of an individual/family, ensure that the individual’s/family’s needs are met, and foster the individual's/family’s autonomy. To accomplish this goal, service coordinators are generally responsible for four types of activities: assessment, planning, implementation, and evaluation. Each activity informs the next, so the cycle is ongoing, and includes:

  • Assure the ASSESSMENT accurately determines the individual’s/family’s current needs and what the individual/family wants to happen in their lives.
  • Coordinate PLANNING of services to meet the needs, wants, preferences, and learning objectives of the individual/family.
  • Assure the IMPLEMENTATION of the service plan.
  • EVALUATE the adequacy of supports and services in meeting the goals and objectives of the individual/family.

Service Coordination should:6

  • Identify the full range of services needed.
  • Identify the range of resources available, including each individual's natural supports and public resources available to the individual/family.
  • Coordinate the activities of all services and resources.
  • Refer individuals/families to all needed resources.
  • Monitor and follow-up to see if services are received.
  • Monitor and follow-along to prevent problems or to identify problems in service provision through on-going contacts with all services utilized, and with the natural support resources (i.e., family and friends).
  • Assess and evaluate the effectiveness of all services or resources used.
  • Continually advocate with and on behalf of each individual/family to maximize quality of life.

6Section adapted from Shaping Case Management in Minnesota ..., 1991.

Service coordinators should base their services on these values: 7

  • Every individual/family has worth.
  • Long-term relationships enhance self-worth.
  • This is an interdependent world where we all share the responsibility to assure the health, education, and welfare of all citizens.
  • Learning is an essential and important part of human existence.

7From Caragonne, 1994.

Service coordinators should ensure that the support provided to the individual/family is consistent with the following principles:

  • Non-intrusive.
  • Easily accessible.
  • Efficient.
  • Growth-enhancing.
  • Promotes inclusion into the community.
  • Involves the opinions, wants, needs and preferences of the individual/family.
  • Age-appropriate.
  • Enhances dignity.
  • Encourages connectedness and friendships.
  • Promotes a positive social role.
  • Protects the rights of the individual/family.
  • Cost-effective.
  • Produces positive changes in the life of the individual/family.
  • Fosters full citizenship of the individual/family.

The life and learning experiences encouraged by service coordinations should:

  • Support and maximize growth.
  • Emphasize the whole person/whole family.
  • Maintain or increase the individual’s/family’s sense of community.
  • Ensure that decision-making by the individual/family is fundamental.
  • Enhance the relationship-building capacity of the individual/family.
  • Occur in a variety of settings.
  • Include the provision of supports and adaptations.
  • Include real experiences and their consequences.

If you are an individual/family who receives services, you should expect your service coordinator to:

  • Treat you with respect.
  • Ask for your opinions.
  • Talk with you and listen carefully when discussing your concerns, your likes and dislikes, what you want to learn or do, etc.
  • Help you with the things you want/need to learn.
  • Help you get the services you may need.
  • Talk with your family or friends, with your permission, if that would be helpful.
  • Give you the opportunity to make your own decisions and/or be involved in making decisions that affect your life.
  • Encourage you to be involved with community activities (recreational, social, religious, work- or school-related, etc.)
  • Ensure you have opportunities to experience new things.
  • Coordinate the annual team meeting and arrange for support and services based on your needs and preferences.
  • Help you become more successful, interdependent, and self-reliant in the life you want to live.
  • Be concerned with your whole life.
  • Protect your rights.
  • Do what he/she promises to do.
  • Be reasonably available when needed.

If you are a person with a disability, your service coordinator should work with you and for you. Your service coordinator should talk with you about your needs, wants, concerns, aspirations, feelings, likes and dislikes regarding:

  • Dental services
  • Medical services
  • Housing
  • School
  • Work
  • Family involvement
  • Friends
  • Community, recreational, and/or social activities
  • Transportation
  • Religious activities
  • Future plans
  • Protecting rights
  • Promoting growth and opportunities
  • Roles and images that support your choices