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. This means that the patient's needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient.

Care coordination in the primary care practice 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.

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.

There are two ways of achieving coordinated care: using broad approaches that are commonly used to improve health care delivery and using specific care coordination activities.

Examples of broad care coordination approaches include:

  • Teamwork
  • Care management
  • Medication management
  • Health information technology
  • Patient-centered medical home

Examples of specific 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 everyone: patients, providers, and payers.

Although the need for care coordination is clear, there are obstacles within the American health care system that must be overcome to provide this type of care. Redesigning a health care system in order to better coordinate patients' care is important for the following reasons:

  • Current health care systems are often disjointed, and processes vary among and between primary care sites and specialty sites.
  • 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.
  • Referral staff deal with many different processes and lost information, which means that care is less efficient.

How Can Care Coordination Be Put Into Action?

Applying changes in the general approach and everyday routines of a medical practice can be overwhelming, even when it is obvious that the changes will improve patient care and provider efficiency. Fortunately, there are resources available for those who are interested in learning how to take a coordinated care approach to primary care practice.

AHRQ has assembled a collection of care coordination resources to help clinicians, clinical teams, and health care administrators measure care coordination and learn more about how to incorporate care coordination into routine primary care practice. These resources include:

The following AHRQ Annual Conference presentations on care coordination are also available:

Care Transitions: Navigating the Health Care System – 2011

So You Think You Can Coordinate Care? Prove It! – 2010

New Knowledge in Care Coordination – 2008

Addressing Problems in Care Coordination – 2007