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How Care Coordination Activities Create the Blueprint for Positive Patient Outcomes

Jon-Michial Carter
Written by Jon-Michial Carter

Care coordination activities help providers offer seamless, effective care and keep patients informed about their health. Launching a care coordination program ensures that all stakeholders, including the patient, their primary care provider, their care coordinator and their specialists, have the right health information to protect patients from treatment gaps, medication conflicts, and unnecessary tests.

In this article, we’ll break down what care coordination is, why it’s important, and how you can implement it for your practice’s patient population.

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. Care coordination programs also ensure that all stakeholders, including the patient, provider, and specialists, are continuously informed of the patient’s health status. Care coordination is important when multiple parties are involved and depend on each other to take care of a patient’s needs.

Care coordination begins with identifying challenges, creating a plan, and reviewing the responsibilities of each party. Once the care plan and care goals are in place, everyone involved comes together to provide an efficient, high-quality level of care for the patient. 

There are different forms of care coordination programs, including Principal Care Management (PCM), Behavioral Health Integration (BHI), and Chronic Care Management (CCM). Which program you offer depends on the needs of your patient population.

What are examples of care coordination activities?

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

  • Medication management and adherence
  • Sharing healthcare information with approved parties
  • Providing educational materials for self-management of conditions
  • Assisting a patient with community resources
  • Supporting health initiatives and care goals
  • Follow-up after healthcare services and procedures
  • Crafting care plans in collaboration with patients
  • Communicating patient needs and changes in patient health status

What a care coordinator does depends on which program the patient is enrolled in and what the patient’s needs are. For example, patients enrolled in Chronic Care Management frequently ask about setting care goals, scheduling appointments, and refilling medications. Some also value the ability to contact a 24-hour nurse line or to receive Social Determinant of Health resources. A CCM care coordinator can address all of these needs.

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 more specific approaches 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 can manage sharing the information and collecting records for documentation. Care coordination can also occur between patients and caregivers, social workers, care team clinicians, or other healthcare providers.

How are care coordination activities tracked? 

Typically, structured care coordination activities and care plans are recorded in the patient’s medical records, which are stored in the EHR and sometimes in other care management platforms. In formal programs like Chronic Care Management, there may be a dedicated, comprehensive care plan  that holds this information that is then pushed to all providers in the care continuum.

The Centers for Medicare & Medicaid Services (CMS) require detailed documentation of activity for programs like CCM and Patient Centered Medical Home (PCMH). The patient, the care coordinator, and the patient’s provider will always have access to their documentation. The provider’s office can use these records to ensure they bill CMS correctly.

Why are care coordination activities important?

Care coordination has the opportunity to greatly impact our healthcare system as a whole. It leads to more effective care, improved quality, and better health outcomes for patients. As our aging population grows and requires more care, care coordination can close care gaps and deliver a higher quality of life for older adults.

For example, patients with multiple providers and chronic conditions have a high risk of gaps in care if providers don’t communicate consistently. With care coordination, these patients’ needs are addressed in a methodical and deliberate way so that nothing is missed. Inpatient readmissions can be reduced, unnecessary ED visits can be avoided, and the patient has better outcomes because their care team communicates with one another consistently.

Moving Forward with Care Coordination Activities

If you think care coordination might be right for your patients, the first step is to explore the different options you have for care coordination: options like ACO-sponsored programs, Principal Care Management, Behavioral Health Integration, and Chronic Care Management.

Practices who serve a large Medicare population can especially benefit from CCM, a program designed specifically to offer care coordination to Medicare patients with multiple chronic conditions. Check out our guide to building a successful CCM program to learn more.

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