Care Coordination

Care coordination involves optimally organizing patient care and information-sharing activities. 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. Coordination among health care providers improves outcomes for everyone by decreasing medication errors, unnecessary or repetitive diagnostic tests, unnecessary emergency room visits, and preventable hospital admissions and readmissions—all of which together lead to higher quality of care, improved health outcomes, and lower costs.

The Institute of Medicine  identifies care coordination as a key strategy that has the potential to improve the effectiveness, safety, and efficiency of the American health care system. And the National Quality Strategy calls all stakeholders to promote effective communication and coordination of care across the health care system by focusing on three long-term goals:

  • Improving the quality of care transitions and communications across care settings.
  • Improving the quality of life for patients with chronic illness and disability by following a current care plan that anticipates and addresses pain and symptom management, psychosocial needs, and functional status.
  • Establishing shared accountability and integration of communities and health care systems to improve quality of care and reduce health disparities.

AHRQ offers tools, research, and data on care coordination.

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Tools

  • Care Coordination Measures Atlas Update
    The Care Coordination Measures Atlas, first published in 2011, is a compendium of existing measures of care coordination. The 2014 update expands that effort, offers new measures with a focus on those that reflect coordination efforts within the primary care setting, and includes a section on emerging trends in care coordination measurement.
  • Care Coordination Accountability Measures for Primary Care Practice
    This report presents measures selected systematically from the Care Coordination Measures Atlas that are well-suited for use by health plans and insurers to assess the quality of coordination in primary care practices and by primary care practices themselves to assess their own performance.
  • Care Coordination Quality Measure for Primary Care
    The Care Coordination Quality Measure for Primary Care (CCQM-PC) is a survey of adult patients’ experiences with care coordination in primary care settings. It was developed to comprehensively assess patient perceptions of the quality of their care coordination experiences. The CCQM-PC is designed to be used in primary care research and evaluation, with potential applications to primary care quality improvement. Guidance regarding the fielding of the survey is provided in addition to the full survey, which is in the public domain and may be used without additional permission.
  • Clinical-Community Relationships Measures Atlas
    The Clinical-Community Relationships Measures Atlas was developed to identify ways to further define, measure, and evaluate programs based on clinical-community relationships for the delivery of clinical preventive services. This Atlas provides a measurement framework and listing of existing measures of clinical-community relationships and is intended to support research and evaluation in the field.
  • Clinical-Community Relationships Evaluation Roadmap
    The Clinical-Community Relationships Evaluation Roadmap addresses clinical-community resource relationships for selected clinical preventive services, but the principles and questions offered may also apply to other clinical and non-clinical services. The Roadmap also may prove applicable to those interested in effective relationships and coordination between clinics and community organizations such as schools or providers of social services.

Research

Data

  • Chartbook on Care Coordination National Healthcare Quality and Disparities Report
    The Care Coordination chartbook includes a summary of quality and disparities across measures of care coordination and figures illustrating select measures of care coordination from the National Healthcare Quality and Disparities Report.