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What Is Care Coordination? Examples, Services, & Best Practices

Care coordination streamlines the delivery of healthcare services. Medications, clinicians, treatment plans, and community resources come together in one harmonious picture of patient health.

This synchronized healthcare model offers an alternative to traditional episodic care, wherein multiple providers give their expertise without communicating with other members of the care team. This siloed approach often yields redundancies that degrade the patient experience and can lead to dangerous mistakes.  

On the other hand, care coordination helps prevent adverse drug interactions, duplicated tests, and gaps in patient care. This prevention supports a better patient experience and improves care effectiveness. 

In this article, we examine the goals of care coordination, give examples and best practices for implementing it, and explore how care coordination offers a solution to fragmented care. We’ll also discuss how Chronic Care Management (CCM) and other care management models support care coordination efforts for Medicare patients.

What is care coordination?

Care coordination is a collaborative approach to organizing and delivering care. It emphasizes communication between all of a patient’s providers, facilitating high-quality and timely care. This patient-centered care model addresses each patient’s specific healthcare conditions and unique wants and needs.  

The goal of care coordination is to improve care outcomes while also promoting greater patient autonomy and engagement. Care coordination can also reduce healthcare costs by improving the efficiency and effectiveness of healthcare services. 

Care coordination involves all key stakeholders in a patient’s health, which may include: 

• Patients 
• Caretakers 
• Providers
• Pharmacists
• Nurses
• Therapists
• Social workers
• Community support organizations 
• Other healthcare specialists 

While the specific care coordination process varies depending on the patient, personalized care plans and clear communication are the cornerstones of any care coordination effort. All providers must be aware of their unique role in supporting patients toward their health goals to reduce the chances of missed or redundant care. 

Care coordination is particularly important in complex health cases. For example, patients with multiple chronic conditions often require treatment from several different providers. Without effective care coordination, these patients may experience poor medication management, unnecessary tests, more reliance on acute care services, and worse overall health outcomes. Effective care coordination ensures the right care is delivered to the right patient at the right time.

What does care coordination involve? 

Regardless of the patient’s unique needs and goals, the following core activities lie at the heart of care coordination. 

• Access to care: For patients to experience the benefits of well-coordinated care, they first must have access to the right providers and specialists. Care coordination seeks to overcome challenges related to healthcare access, ensuring patients can obtain the care they need. 
• Communication: Proactive communication through a centralized platform, such as an electronic health record (EHR), is essential to keep stakeholders in the loop about any health developments and deliver timely care. 
• Care planning: Defining personalized patient goals, including specific timelines and benchmarks, helps unify disparate care instances and providers around a specific objective. 
• Care transitions: Care coordination includes support for patients transitioning from one healthcare setting to another. These efforts help reduce gaps in care and prevent critical information from being lost in the move. 
• Community resources: Care coordination services often include connections to community resources, such as organizations that address SDOH. This component of care coordination ensures whole-patient support. 
• Patient follow-up: As part of care coordination efforts, patients can become informed and engaged participants in their healthcare. Touching base with patients between procedures or care visits and educating them on their conditions gives patients greater autonomy. They become better equipped to voice concerns and notice symptoms, which supports early, preventive care. They can also contribute to setting their own care goals, which makes them more likely to pursue and achieve those goals. 

How to approach care coordination in your practice

Pursuing more coordinated care has many advantages for your patients, including better outcomes. To improve patient experience, all while reducing healthcare costs, take these practical steps toward better care coordination. 

Embrace transparency

Both the patient and other stakeholders involved in the patient's care must have visibility into the care you deliver. A shared understanding of the patient’s health supports better care decisions and helps patients self-manage their conditions. 

Leverage your electronic health record

Tap into your EHR as the single source of truth for patient health data. Used correctly, this critical tool supports seamless communication and better decision-making. Having digital access to health records also makes it easier to reference past treatment, promote patient self-management, and facilitate timely follow-up. 

Develop personalized care plans 

Instead of using a one-size-fits-all treatment lens, care coordination requires a tailored approach. Your recommendations, prescriptions, and referrals should consider the patient’s broader picture of health. Work with patients to understand their unique preferences and goals. Then, incorporate this information to craft highly specific care plans centered around patients’ wants and needs. 

Educate and engage your patients 

Engaging patients in the healthcare process is a critical component of care coordination. Patients and their caregivers should be included and informed throughout the care delivery process. Instead of assuming a level of medical knowledge, take time to explain medical diagnoses and conditions, thereby equipping patients to become active participants in their healthcare trajectory. It’s also important to provide abundant educational materials available via text, email, patient portal, or physical mail. 

Adopt a care coordination program 

The Centers for Medicare & Medicaid Services (CMS) supports care coordination through programs designed to encourage preventive, patient-centered care. Each program offers a framework to facilitate care coordination for a specific patient population. Chronic Care Management or CCM, for example, is tailored around the needs of Medicare patients with two or more chronic conditions, while Advanced Primary Care Management (APCM) supports patient engagement through Medicare patient check-ins between primary care visits. Adopting the right program for your patient population can be your best next step toward more coordinated care. 

Care coordination examples

Delivering well-coordinated care takes many different forms depending on a patient’s needs, provider setting, and available resources. The following examples illustrate what care coordination can look like in practice. 

Sharing health information

One foundational aspect of care coordination is timely, transparent information-sharing among the care team. Providers should communicate care recommendations to the patient as well as other approved clinicians, specialists, and caregivers involved in that patient’s treatment. For example, a cardiologist treating a patient with heart disease might consult the patient’s cardiac surgeon and primary care physician on treatment. This level of collaboration reduces duplicate testing, closes care gaps, and creates a more unified experience for the patient—especially important in complex or high-risk cases.

Creating a personalized health plan

Care coordination involves detailed, individualized plans centered around health goals. For a patient with diabetes, a personalized care plan might include a tailored diet and exercise regimen developed with a dietitian, scheduled medication refills managed by the pharmacy, routine lab work, and monthly CCM or APCM check-ins to track progress and adjust goals. Everyone on the care team—from the endocrinologist to the primary care provider to the care coordinator—contributes to and is accountable for different elements of the plan. This ensures the patient’s needs are addressed holistically and proactively. 

Managing medication

Medication reconciliation is a critical component of care coordination, particularly for patients who see multiple specialists or take numerous prescriptions. Before prescribing a medication, providers should check patient records for any unwanted drug interactions or side effects that could hinder the patient’s care goals and preferences. For instance, a patient managing heart failure, diabetes, and arthritis may be prescribed medications from three different providers. Without coordinated oversight, this could lead to dangerous overlaps or side effects. In a well-coordinated practice, the care team works together to streamline prescriptions, educate the patient, and reduce unnecessary polypharmacy—all while supporting adherence and long-term health outcomes. 

Assigning a dedicated care coordinator 

Patients benefit significantly from having a dedicated care manager who serves as their consistent point of contact within the healthcare system. In a CCM program, for example, the care coordinator plays a central role in supporting patients between visits—answering questions, scheduling appointment follow-ups if the patient needs assistance, checking on  referrals, and ensuring medication adherence. They also act as the bridge between the patient and the broader care team, communicating updates to primary care providers and specialists to ensure everyone remains aligned on the care plan. 

This level of hands-on support helps patients feel more connected, improves continuity of care, and reduces the risk of missed information or fragmented treatment—particularly for those with multiple chronic conditions who frequently move between providers or care settings.

The challenges of fragmented care

Without care coordination, care often becomes disjointed. Fragmented care puts patients at greater risk of poor healthcare experiences and outcomes. Providers must be aware of the common symptoms of uncoordinated care. 

• Duplicate care efforts: Fragmented care can result in redundancy, including duplicate tests, treatments, or screenings, which increase healthcare costs and contribute to patient frustration.
• Medication mismanagement: When care is not coordinated, medication errors can occur, like adverse drug interactions, duplicate treatments, or poorly managed side effects that inhibit health progress. 
• Lack of patient communication: Fragmented care alienates patients and often leads to confusion about their condition, how to self-manage their symptoms, and what steps to take to improve their health. 
• Negative health outcomes: Care that is not well-coordinated can result in patients seeking acute care that could have been prevented with timely interventions. Disjointed care can also result in poorer medication and treatment adherence, which can have a poor impact on patient health. 

What chronic care coordination looks like in practice

Nearly half of all Americans have at least one chronic condition, making chronic care a central focus of any effective care coordination strategy. For providers, this means going beyond episodic treatment and building systems that offer continuous support between visits. 

One of the most impactful ways to approach this is by implementing a formal care management program, like Chronic Care Management. This Medicare-supported program is designed to reduce hospitalizations, improve quality of life, and boost health outcomes for patients with two or more chronic conditions. Through structured monthly outreach, personalized care planning, medication support, and coordination across providers, CCM makes proactive, preventive care both actionable and reimbursable. 

Likewise, programs like Advanced Primary Care Management (APCM) can also help providers close the gap between visits with ongoing patient check-ins for patients of varying risk levels. Unlike other care management programs such as CCM, APCM is designed to create a cadence of preventive care for any Medicare patients, regardless of whether or not they suffer from chronic conditions. Dedicated care managers regularly engage with patients, supporting them through care transitions, helping with medication refills and scheduling, and connecting them to community resources. 

Choosing the right approach depends on your patient population and practice resources. Many practices find success by partnering with a full-service provider like ChartSpan, which offers the infrastructure and clinical staff needed to implement care coordination at scale—without overburdening your internal team. This kind of partnership can make care coordination not only possible but also sustainable long-term.

ChartSpan's care coordination services for CCM and APCM

For our Chronic Care Management and Advanced Primary Care Management partners, we take on most of the care coordination responsibility, freeing providers up to focus on the delivery of care services. We offer dedicated support that most providers can’t match with their existing staff, including these key services. 

• 24/7 care line: We staff and maintain an around-the-clock care line, giving patients a critical channel to voice concerns and receive timely care before their needs become more acute. 
• Personalized care plans: Our care managers collaborate with patients to develop care plans that reflect their preferences and meet provider-set goals. As patient needs change, we revisit the plans to ensure they are closely linked with individual health. 
• Social Determinants of Health (SDOH): We take a broad view of health, identifying areas to support patients through challenges like transportation needs, community connection, and healthcare access. 
• Appointment scheduling: ChartSpan supports practices with patient scheduling and can remind patients of upcoming appointments. 
• Medication refills: We inform patients of upcoming or missed medication refills to reduce gaps in treatment and promote adherence to provider-prescribed regimens. 
• Regular patient check-ins: ChartSpan takes the burden of patient check-ins off of busy providers, promoting care continuity and preventive care interventions. 
• Patient education: From diagnosis to treatment and every step along the way, we supplement provider notes with patient education materials to support self-management. 
• Care documentation: We help to ensure the patient's health record is accurate and up-to-date with clear record-keeping support that complies with Medicare requirements. 

Interested in supporting care coordination through CCM or APCM? Speak with one of our experts to learn how Chartspan can help. 

You might also like: 

• How Care Coordination Activities Create the Blueprint for Positive Patient Outcomes
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