Chapter 2. What is Care Coordination? (2022)

Care coordination means different things to different people; no consensus definition has fully evolved. A recent systematic review identified over 40 definitions of the term "care coordination."2 The systematic review authors combined the common elements from many definitions to develop one working definition for use in identifying reviews of interventions in the vicinity of care coordination and, as a result, developed a purposely broad definition: "Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care." For some purposes, they noted that other definitions may be more appropriate. This lack of consensus is perhaps not surprising given the many different participants involved in coordinating care.

In this section we provide a visual definition (go to Figure 1) and scenarios to help illustrate care coordination in the absence of a consensus definition. This visual definition may be helpful to some Atlas users, and less so to others. Several additional illustrations of care coordination are presented in a recent monograph on quality of cancer care.3

The central goal of care coordination is shown in the middle of the diagram. The colored circles represent some of the possible participants, settings, and information important to care pathways and workflow. The blue ring that connects the colored circles is Care Coordination—namely, anything that bridges gaps (white spaces) along the care pathway (i.e., care coordination activities or broad approaches hypothesized to improve coordination of care). For a given patient at a given point in time, the bridges or ring need to form across the applicable circles, and through any gaps within a given circle, to deliver coordinated care.

Perspectives on Care Coordination

Successes and failures in care coordination will be perceived (and may be measured) in different ways depending on the perspective: patient/family, health care professional(s), or system representative(s). Consideration of views from these three potentially different perspectives is likely to be important for measuring care coordination comprehensively.

(Video) Care Coordination Training Module 2 - Defining Care Coordination

Patient/Family Perspective. Care coordination is any activity that helps ensure that the patient's needs and preferences for health services and information sharing across people, functions, and sites are met over time.4

Patients, their families, and other informal caregivers experience failures in coordination particularly at points of transition. Transitions may occur between health care entities (see definition under "additional terms") and over time and are characterized by shifts in responsibility and information flow. Patients perceive failures in terms of unreasonable levels of effort required on the part of themselves or their informal caregivers in order to meet care needs during transitions among health care entities.

Health Care Professional(s) Perspective. Care coordination is a patient- and family-centered, team-based activity designed to assess and meet the needs of patients, while helping them navigate effectively and efficiently through the health care system. Clinical coordination involves determining where to send the patient next (e.g., sequencing among specialists), what information about the patient is necessary to transfer among health care entities, and how accountability and responsibility is managed among all health care professionals (doctors, nurses, social workers, care managers, supporting staff, etc.). Care coordination addresses potential gaps in meeting patients' interrelated medical, social, developmental, behavioral, educational, informal support system, and financial needs in order to achieve optimal health, wellness, or end-of-life outcomes, according to patient preferences.5

Health care professionals notice failures in coordination particularly when the patient is directed to the "wrong" place in the health care system or has a poor health outcome as a result of poor handoffs or inadequate information exchanges. They also perceive failures in terms of unreasonable levels of effort required on their part in order to accomplish necessary levels of coordination during transitions among health care entities.

System Representative(s) Perspective. Care coordination is the responsibility of any system of care (e.g., "accountable care organization [ACO]") to deliberately integrate personnel, information, and other resources needed to carry out all required patient care activities between and among care participants (including the patient and informal caregivers). The goal of care coordination is to facilitate the appropriate and efficient delivery of health care services both within and across systems.

Failures in coordination that affect the financial performance of the system will likely motivate corrective interventions. System representatives will also perceive a failure in coordination when a patient experiences a clinically significant mishap that results from fragmentation of care.6

Additional Terms. Definitions for additional terms relating to care coordination are presented below.

(Video) What is Care Coordination? 4 Components You Need to Know

Health care entities. Health care entities are discrete units of the health care system that play distinct roles in delivery of care. The context and perspective will determine who precisely those units are. For example:

  • From a patient and family perspective, entities are likely to be individual health care providers with whom the patient and family interact, such as nurses, physicians, and support staff.
  • From a health care professional perspective, entities may be individual members of a work group, such as nurses, physicians, and support staff in a particular clinic. Or they may be provider groups, such as a primary care practice, specialty practice, or urgent care clinic.
  • From a system representative(s) perspective, entities will likely be groups of providers acting together as a unit, such as medical units in a hospital, hospitals as a whole, specialty clinics within an integrated system, or different clinical settings within the health care system overall (i.e., ambulatory care, inpatient care, emergency care).

Points of transition. Transitions occur when information about or accountability/responsibility for some aspect of a patient's care is transferred between two or more health care entities, or is maintained over time by one entity. Often information and responsibility are (or should be) transferred together.

It may be useful to think about two broad categories of transitions:

  1. Transitions between entities of health care system. Information transfer and/or responsibility shifts:
    • Among members of one care team (receptionist, nurse, physician)
    • Between patient care teams
    • Between patients/informal caregivers and professional caregivers
    • Across settings (primary care, specialty care, inpatient, emergency department)
    • Between health care organizations
  2. Transitions over time. Information transfer and/or responsibility shifts:
    • Between episodes of care (i.e., initial visit and followup visit)
    • Across lifespan (e.g., pediatric developmental stages, women's changing reproductive cycle, geriatric care needs)
    • Across trajectory of illness and changing levels of coordination need

Figure 1. Care Coordination Ring

Chapter 2. What is Care Coordination? (1)

[D] Select for Text Description.

The central goal of care coordination is shown in the middle of the diagram. The colored circles represent some of the possible participants, settings, and information important to the care pathway and workflow. The blue ring connecting the colored circles is Care Coordination—namely, anything that bridges gaps (white spaces) along the care pathway (i.e., care coordination activities or broad approaches hypothesized to improve coordination of care. Go to Figure 2). Successes and failures in care coordination will be perceived (and may be measured) in different ways depending on the perspective: patient/family, health care professional(s), or system representative(s).

(Video) Chapter 2: The Medical Assistant and the Healthcare Team

Example Scenarios

The level of care coordination need will increase with greater system fragmentation (e.g., wider gaps between circles), greater clinical complexity (e.g., greater number of circles on ring), and decreased patient capacity for participating effectively in coordinating one's own care, as illustrated by the following scenarios. The level of need is not fixed in time, nor by patient. Assessment of level of care coordination is likely important to tailor interventions appropriately and to evaluate their effectiveness.

Scenario 1. Mrs. Jones is a healthy 55-year-old woman. She visits her primary care provider, Dr. I. Care, once a year for a routine physical. Dr. Care practices in a primary care clinic with an electronic medical record (EMR) system and on-site laboratory and radiology services. At Mrs. Jones' annual physical, Dr. Care ordered several blood tests to evaluate her cholesterol and triglyceride levels. Mrs. Jones also mentioned that she is having lingering pain in her ankle after a previous sprain. Dr. Care ordered an x-ray. After receiving the blood test results via the electronic medical record system, Dr. Care sees that Mrs. Jones' cholesterol is high and prescribes a medication. She submits the prescription directly to the pharmacy via a link from the EMR. She receives electronic notification that the x-ray does not show any fracture. She calls Mrs. Jones to refer her to a nearby physical therapy practice. Mrs. Jones picks up her medication from the pharmacy and calls the physical therapist to schedule an appointment.

Scenario 1. Visual
Complexity: Low
Fragmentation: Low
Patient Capacity: High
Care Coordination Need: Minimal

Chapter 2. What is Care Coordination? (2)

[D] Select for Text Description.

Scenario 2. Mr. Andrews is a 70-year-old man with congestive heart failure and diabetes. He uses a cane when walking and recently has had some mild memory problems. His primary care physician, Dr. Busy, is part of a small group physician practice focused on primary care. The primary care clinic includes a laboratory, but they refer their radiology tests to a nearby radiology center. Mr. Andrews also sees Dr. Kidney, a nephrologist, and Dr. Love, a cardiologist. Both specialists are part of a specialty group practice that is not affiliated with Dr. Busy's clinic. Their specialty practice includes an on-site laboratory, radiology clinic, and pharmacy. Mr. Andrews has prescriptions filled at the specialty clinic pharmacy after his appointments with Drs. Kidney and Love and picks up medications prescribed by Dr. Busy at a pharmacy near his home. Mr. Andrews has a daughter who lives nearby but works full time. Because he has trouble getting to the grocery store to do his shopping, he receives meals at his home 5 days a week through a meals-on-wheels senior support service. His daughter has hired a caregiver to help Mr. Andrews with household tasks for two hours three days a week.

During a recent meal delivery, the program staffer noticed that Mr. Andrews seemed very ill. He called an ambulance, and Mr. Andrews was taken to the emergency department. There he was diagnosed with a congestive heart failure exacerbation and was admitted. During his initial evaluation, the admitting physician asked Mr. Andrews about which medications he was taking, but the patient could not recall what they were or the doses. The physician on the hospital team contacted Dr. Busy, who provided a medical history and general list of medications. Dr. Busy noted that Mr. Andrews may have had dosing changes after a recent appointment with Dr. Love. In addition, Dr. Busy noted that Mr. Andrews may be missing medication doses because of his forgetfulness. He provided the hospital team with contact information for Drs. Love and Kidney. He also asked that a record of Mr. Andrews' hospital stay be sent to his office upon his discharge.

(Video) What Is Patient Care Coordination?

Mr. Andrews was discharged from the hospital one week later. Before going home, the nurse reviewed important information with him and his daughter, who was taking him home. They went over several new prescriptions and details of a low-salt diet. She told him to schedule a followup appointment with his primary care physician within 2 days and to see his cardiologist in the next 2 weeks. Mr. Andrews was very tired so his daughter picked up the prescriptions from a pharmacy near the hospital, rather than the one Mr. Andrews usually uses.

Scenario 2. Visual
Complexity: High
Fragmentation: Moderate
Patient Capacity: Low
Care Coordination Need: Extensive

Chapter 2. What is Care Coordination? (3)

2 McDonald KM, Sundaram V, Bravata DM,et al. Care coordination. In: Shojania KG, McDonald KM, Wachter RM, and Owens DK, eds. Closing the quality gap: A critical analysis of quality improvement strategies. Technical Review 9 (Prepared by Stanford-UCSF Evidence-Based Practice Center under contract No. 290-02-0017). Vol. 7. Rockville, MD: Agency for Healthcare Research and Quality, June 2007. AHRQ Publication No. 04(07)-0051-7.
3 Taplin SH, Rodgers AB. Toward improving the quality of cancer care: Addressing the interfaces of primary and oncology-related subspecialty care. J Natl Cancer Inst Monogr 2010;40:3-10.
4 Adapted from information published by the National Quality Forum.
5 Adapted from information published in: Antonelli RC, McAllister JW, Popp J. Making care coordination a critical component of the pediatric healthcare system: A multidisciplinary framework. New York: The Commonwealth Fund; 2009.
6 Adapted from information published in: McDonald KM, Sundaram V, Bravata DM, et al. Care coordination. In: Shojania KG, McDonald KM, Wachter RM, and Owens DK, eds. Closing the quality gap: A critical analysis of quality improvement strategies. Technical Review 9 (Prepared by Stanford-UCSF Evidence-Based Practice Center under contract No. 290-02-0017). Rockville, MD: Agency for Healthcare Research and Quality, June 2007. AHRQ Publication No. 04(07)-0051-7.

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FAQs

What is meant by care coordination? ›

Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care.

What is care coordination NHS? ›

Care coordinators provide extra time, capacity, and expertise to support patients in preparing for clinical conversations or in following up discussions with primary care professionals.

What are the principles of care coordination? ›

Principles of care coordination reflect the central role of families and the prioritization of child and family concerns, strengths and needs in effective care of children with special health care needs.

What does coordination mean in health and social care? ›

We think that coordination means: working together across multiple aspects of care to help everyone involved in a patient's care to avoid repetition and achieve shared goals. We say that care must be coordinated throughout a person's whole life, across all parts of the health and care system.

What is Care coordination and why is it important? ›

Care coordination is a patient- and family-centered, team-based activity designed to assess and meet the needs of patients, while helping them navigate effectively and efficiently through the health care system.

Why is it important to coordinate care? ›

The goals of coordinated care are to improve health outcomes by ensuring that care from disparate providers is not delivered in silos, and to help reduce health care costs by eliminating redundant tests and procedures.

What is care coordination in nursing UK? ›

The care coordination service aims to keeps patients with complex health and care needs well at home. You can access this service if you: Are over 18 years old, have a GP in Ealing and live within 1 mile of the borough. Need help to find your way around different health and social care services.

What is the role of a patient care coordinator? ›

They listen to patients and their families to ensure needs are being addressed, educate patients on medical procedures or conditions, keep patient records up to date, and act as a liaison between the patient and healthcare personnel by keeping the lines of communication flowing.

How do I become a good care coordinator? ›

Skills and qualifications of a care coordinator
  1. Technical skills. Computer skills, including Microsoft Office. ...
  2. Personal skills. Excellent communicator. ...
  3. Degree. ...
  4. Experience. ...
  5. Local licensure. ...
  6. Optional certifications. ...
  7. Related articles.
25 Aug 2022

What are the six steps of the care coordination process? ›

The Population Care Coordination Process involves six phases: data analysis, selection, assessment, plan- ning, interventions, and evaluation (see Figure 1 ). While the process is generally linear, steps can be repeated as necessary particularly if additional infor- mation, assessment, or analysis is required.

What are the 5 principles of care? ›

The Standards are built upon five principles; dignity and respect, compassion, be included, responsive care and support and wellbeing.

When did care coordination start? ›

Models of care coordination are not new. The principles of the "medical home" were first proposed by the American Academy of Pediatrics in 1967 for the care of special needs children.

What are the four elements of coordinated care? ›

They are:
  • A Holistic Understanding of a Particular Patient's Health Needs.
  • Streamlined Access to Care Services and Providers.
  • Concise, Actionable Information to Support Patient Engagement.
  • Strong Communication to Help Coordinate Care Transitions.
6 Apr 2022

How do you coordinate care? ›

Specific activities used to achieve coordinated care include:
  1. Establishing accountability and agreeing on responsibility.
  2. Communicating and sharing knowledge.
  3. Helping with transitions of care.
  4. Assessing patient needs and goals.
  5. Creating a proactive care plan.
3 Jun 2022

What is the difference between care coordination and care management? ›

Care management, at its core, focuses on high-touch and episodic interactions; care coordination attempts to provide more longitudinal or holistic care.” Each of these tasks requires a slightly different set of stakeholders and its own unique health IT functionalities.

Why is care coordination important in nursing? ›

Care coordination promotes greater quality, safety, and efficiency in care, resulting in improved healthcare outcomes and is consistent with nursing's holistic, patient-centered framework of care.

What is another name for care coordinator? ›

Professional care coordinators may be called discharge planners, benefit managers, case managers, private geriatric care managers, or some other title. They may work in a: Health care facility such as a hospital, outpatient clinic, medical practice, VA hospital or clinic, or primary care doctor's office.

How does care coordination improve patient outcomes? ›

Care Coordination allows physicians and other care team members to focus on proactive care, rather than react to expensive acute care episodes. Engage patients in their own care. As extensions of the physician and his/ her care team, PCCs can stay closely connected to patients.

What is coordinated care in person Centred care? ›

Person-Centred Coordinated Care (P3C) is perceived as a way of achieving better outcomes for patients and improved efficiency for health and care economies. We have defined person-centred and coordinated care as: 'Care that is guided by and organised effectively around the needs and preferences of the individual'

Why is care coordination important in nursing? ›

Care coordination promotes greater quality, safety, and efficiency in care, resulting in improved healthcare outcomes and is consistent with nursing's holistic, patient-centered framework of care.

How do you coordinate care? ›

Specific activities used to achieve coordinated care include:
  1. Establishing accountability and agreeing on responsibility.
  2. Communicating and sharing knowledge.
  3. Helping with transitions of care.
  4. Assessing patient needs and goals.
  5. Creating a proactive care plan.
3 Jun 2022

What are the six steps of the care coordination process? ›

The Population Care Coordination Process involves six phases: data analysis, selection, assessment, plan- ning, interventions, and evaluation (see Figure 1 ). While the process is generally linear, steps can be repeated as necessary particularly if additional infor- mation, assessment, or analysis is required.

What is another name for care coordinator? ›

Professional care coordinators may be called discharge planners, benefit managers, case managers, private geriatric care managers, or some other title. They may work in a: Health care facility such as a hospital, outpatient clinic, medical practice, VA hospital or clinic, or primary care doctor's office.

How does care coordination improve patient outcomes? ›

Care Coordination allows physicians and other care team members to focus on proactive care, rather than react to expensive acute care episodes. Engage patients in their own care. As extensions of the physician and his/ her care team, PCCs can stay closely connected to patients.

How can care coordination be improved? ›

Five Key Steps for Better Healthcare Coordination
  1. Step 1: Champion Your Patient-Centric Mission and Vision. ...
  2. Step 2: Find and Celebrate Short-Term Accomplishments. ...
  3. Step 3: Get Everyone Talking. ...
  4. Step 4: Pay Attention to Workflows. ...
  5. Step 5: Know Your Technology Capabilities.
5 Jun 2020

When did care coordination start? ›

Models of care coordination are not new. The principles of the "medical home" were first proposed by the American Academy of Pediatrics in 1967 for the care of special needs children.

What are the duties of a care coordinator? ›

Care Coordinators facilitate conversations between interdisciplinary Care Teams (including Patient Navigators, Care Coordinators, primary care physicians, and additional health care providers) and expedite client services referrals.

What are the duties and responsibilities of a patient care coordinator? ›

Job Responsibilities of a Patient Care Coordinator

Perform analytical and data entry task. Answer patient calls, emails and questions, including finding insurance estimates. Confidentially manage patient accounts. Schedule patient visits and answer pre-visit questions, including about billing.

What is the difference between care coordination and care management? ›

Care management, at its core, focuses on high-touch and episodic interactions; care coordination attempts to provide more longitudinal or holistic care.” Each of these tasks requires a slightly different set of stakeholders and its own unique health IT functionalities.

What do patient care coordinators wear? ›

A patient coordinator has to wear a business type attire. They don't have to wear scrubs.

Does care coordination work? ›

Care coordination has been identified as an important way to improve how the healthcare system works for patients, especially in terms of improved efficiency and safety.

What qualifications do I need to be a care coordinator? ›

To work as a care coordinator, you need a degree in business, communication or any related medical field such as health care administration. Although most employers prefer individuals with a bachelor's degree, you can secure the job with a nurse training program or associate degree.

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