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How Care Coordination Activities Create the Blueprint for Positive Patient Outcomes

Written by Jon-Michial Carter

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What is “Care Coordination?”

Care coordination is when patient care activities are deliberately organized and executed to meet the needs and preferences of the patient. It ensures that all stakeholders, including the patient, provider, and specialists are informed of the patient’s health status every step of the way. Care coordination is important when multiple parties are involved and depend on each other to take care of a patient’s needs. In this situation, the care coordination begins with identifying challenges, creating a plan, and reviewing the responsibilities of each party. Once the care plan is in place, the coordinated care activities come together to provide an efficient, high-quality level of care for the patient. 

What are examples of care coordination activities?

Examples of care coordination activities include but are not limited to: 

• Medication management and adherence
• Sharing documented healthcare information with approved parties
• Assisting a patient with community resources
• Supporting health initiatives and wellness goals
• Follow-up after health care services and procedures
• Transitional care
• Communicating patient needs and changes in patient health status

Who is responsible for care coordination? 

There are several different approaches to care coordination. These can range from something as broad as individual providers working together, to a more specific approach like a Chronic Care Management (CCM) program. Since the approach can vary so widely, nearly all healthcare providers can carry out care coordination activities in some way. Oftentimes, the activities occur between separate healthcare organizations. For example, primary care physicians often do not receive information about what occurs during a specialty referral and vice versa. If the patient has a dedicated care team or care coordinator, like in a Chronic Care Management program, that care team is responsible for sharing the information and collecting records for documentation. Care coordination can also occur between patients and caregivers, social workers, care team clinicians, or other health care providers. 

How are care coordination activities tracked? 

Typically, structured care coordination activities and care plans are recorded in the patient’s medical records and stored in the EHR. In more organized programs like Chronic Care Management, there may be a dedicated, comprehensive document that holds this information that is then pushed to all providers in the care continuum. The Centers for Medicare and Medicaid (CMS) require detailed documentation of activity for programs like CCM and Patient Centered Medical Home (PCMH). 

Why are care coordination activities important?

Care coordination has the opportunity to greatly impact our health care system as a whole. Its activities lead to more effective care, improved quality, and better health outcomes for patients. As our aging population grows and requires more care needs, care coordination can close care gaps and deliver a higher quality of life for our population. For example, complex patients with multiple providers and chronic conditions tend to create the opportunity for gaps in care. With care coordination, these patients’ needs are addressed in a methodical and deliberate way so that nothing is missed. Readmissions are reduced, ED visits are avoided, and the patient has better outcomes simply because their care team was paying attention and addressing the situation.