Care Coordination

What Is Care Coordination?

Care coordination involves 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.

The main goal of care coordination is to meet patients’ needs and preferences in the delivery of high-quality, high-value health care. This means that the patient’s needs and preferences are known and communicated at the right time to the right people and that this information is used to guide the delivery of safe, appropriate, and effective care.

Examples of care coordination activities include:

  • Establishing accountability and agreeing on responsibility.
  • Communicating/sharing knowledge.
  • Helping with transitions of care.
  • Assessing patient needs and goals.
  • Creating a proactive care plan.
  • Monitoring and followup, including responding to changes in patients’ needs.
  • Supporting patients’ self-management goals.
  • Linking to community resources.
  • Working to align resources with patient and population needs.

 

Why Is Care Coordination Important?

Care coordination is identified by the Institute of Medicine as a key strategy that has the potential to improve the effectiveness, safety, and efficiency of the American health care system. Well-designed, targeted care coordination that is delivered to the right people can improve outcomes for the patients.

  • Patients are often unclear about why they are being referred from primary care to a specialist, how to make appointments, and what to do after seeing a specialist.
  • Specialists do not consistently receive clear reasons for the referral or adequate information on tests that have already been done. Primary care physicians do not often receive information about what happened in a referral visit.

Care Coordinators can ensure that all of these processes happen smoothly and everyone is informed on what is happening with the patient.