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
- American College of Physicians High Value Care Coordination Toolkit
- American Psychiatric Association FAQs for PCPs on Collaborative Care
Best Practice for Special Populations
- Centers for Disease Control and Prevention Care Coordination When Prescribing Opioids for Chronic Pain
- Centers for Disease Control and Prevention Care Coordination for School Age Children
- Centers for Disease Control and Prevention Care Coordination for HIV/AIDS Population
- Centers for Disease Control and Prevention Care Coordination for People with Asthma
- Substance Abuse and Mental Health Services Administration Care Coordination for Certified Community Behavioral Health Clinics (CCBHCs)
- Rural Health Information Hub Care Coordination for Rural Populations
Healthcare Effectiveness Data and Information Set (HEDIS®) 
- HEDIS measures encompass elements of care coordination and their related activities. Beacon has a comprehensive list of HEDIS Tip Sheets for more information.
- Agency for Healthcare Research and Quality Care Coordination Quality Measure for Primary Care (CCQM-PC)
- Complete Care Plan
- There are useful applications for IOS and Android operating systems that can track this information electronically for patients and family members and are widely available through a browser search.
- Care Transition Guide
- Appointment Tracker
- Medication Record
- My Crisis Plan App
1 Care Coordination. Content last reviewed August 2018. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/ncepcr/care/coordination.html
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 https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0291