Coordination of Care

Care coordination is a key piece of Continuity of Care, defined by the American Academy of Family Physician: “Continuity of Care is concerned with quality of care over time. It is the process by which the patient and his/her physician-led care team are cooperatively involved in ongoing healthcare management toward the shared goal of high quality, cost-effective medical care. Continuity of care is rooted in a long-term patient-physician partnership in which the physician knows the patient’s history from experience and can integrate new information and decisions from a whole-person perspective efficiently without extensive investigation or record review. Continuity of care is facilitated by a physician-led, team-based approach to healthcare. It reduces fragmentation of care and thus improves patient safety and quality of care.”

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 healthcare system. Well-designed, targeted care coordination that is delivered to the right people can improve outcomes for everyone: patients, providers, and payers.1

The Agency for Healthcare Research and Quality (AHRQ) defines Care Coordination as 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.

Care coordination is a broad term and can have different meanings across healthcare settings. Best practices in care coordination should include a model that establishes common language, sets expectations, and educates the care team to ensure all care team members are in alignment. The model should include clear definitions and criteria for predictive analytics and risk stratification of the patient population. Strong risk stratification provides a method to tailor care to those individuals who are at greater risk. The care coordination model should also include:

  • Identification of the interdisciplinary care team, including medical, behavioral, pharmacy, and social team members, to address all health-related individual needs, enabling all members of the care team to work across the continuum
  • Comprehensive assessment to identify the members’ needs and barriers to care
  • Communication strategy such as rounds, warm handoffs, and connected Electronic Health Records or Electronic Medical Records (EHR/EMR) to allow for early intervention and preventative measures to keep members healthy
  • Robust monitoring system for follow-up care
  • Methods to address polypharmacy and indiscriminant use of Benzodiazepines and other controlled substances
  • Ongoing improvement activities to evaluate interventions, monitor quality, and refine predictive analytics and risk stratification methodologies

Best Practice

Best Practice for Special Populations

Healthcare Effectiveness Data and Information Set (HEDIS®) [2]

Tip Sheets

Member Materials

1 Care Coordination. Content last reviewed August 2018. Agency for Healthcare Research and Quality, Rockville, MD.
2 HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
3 What is Care Coordination? Content last reviewed January 2018 New England Journal of Medicine (NEJM) Catalyst