Care Coordination

Defining key terms:

  • Care Coordination: The organization of a patient’s care across multiple health care providers. (Healthcare.gov)
     
  • Fragmented Care:  When health care providers don’t communicate effectively with each other around a patient’s care, resulting in – for example – repeated lab tests, drugs that don’t work when you take them together, more trips to the doctor’s office that could have been handled with a phone call, and other negative impacts that lead to confusion and higher out-of-pocket costs for patients.

Why Care Coordination is Important

Image shoring a diverse group of four care providers with their hands stacked in the middle - go team!

When doctors and other health care providers work together and share information, patient's needs and preferences are known and communicated at the right time to the right people, and the information is used to provide safe, appropriate, and effective care. This can help to keep patients healthier longer, better manage chronic conditions and experience care that is consistent with their goals.

When doctors and other health care providers don’t communicate effectively with each other treatments prescribed by different doctors for a patient’s different health issues might conflict or become unmanageable for the patient. The patient is more likely to get unnecessary repeat tests. Worse yet, lack of coordination can lead to negative health outcomes for patients, more use of emergency care, medication errors, poor transitions of care from hospital to home, and medical errors. These effects can have a larger negative impact on chronically ill patients or patients with multiple complex health conditions.

When Care Needs to Be Coordinated

There are several different points of contact in which care might need to be coordinated. That can include:

  • Follow up care after an emergency hospital visit.
  • Care between a patient’s primary care provider and multiple specialists for a chronic health condition.
  • A temporary stay in a skilled nursing facility.
  • Health care providers coordinating with social services to help a patient with social determinants of health, such as housing, transportation or food.

How Providers Coordinate Patient Care

There are several ways doctors and other healthcare providers can work together to coordinate a patient’s care. For example:

  • Use of electronic health records. Doctors can use the same platform for their electronic health records so that each provider can see and update a patient’s medical history, and communicate with the patient through an electronic app.
  • Join an Accountable Care Organization (ACO). Groups of doctors, hospitals, and other health care professionals join and work together in an ACO to give patients high-quality, coordinated service and health care, improve health outcomes, and manage costs. ACOs may be in a specific geographic area and/or focused on patients who have a specific condition, like chronic kidney disease. ACOs often help facilitate greater communication between primary care doctors and specialists and may connect patients with social services.
  • Take part in a program or model. Providers may take part in a CMS Innovation Center model, Medicare Shared Savings Program, or another program that supports care coordination. These programs may help advise on how doctors can work together and reward successful coordination that promotes better patient health.

An example of coordinated care

The example below illustrates how patients can benefit from primary care.

When emergency, primary and specialty doctors work in sync

Mary, 70, goes to the hospital emergency department after feeling chest pain and shortness of breath. A doctor examines her, orders tests and diagnoses her with a heart attack. The doctor’s notes, Mary’s test results and newly prescribed medication are entered into Mary’s electronic health record and an alert is automatically sent to Mary’s primary care doctor.

Mary is also referred to a heart specialist (cardiologist), who accesses Mary’s electronic health record during her appointment to review Mary’s previous test results and add new information about Mary’s condition and care plan. Following the cardiology appointment, Mary’s primary care physician examines the medical record and checks in with Mary to see how she’s doing.


Learn More about how the CMS Innovation Center Supports Care Coordination

Read a CMS blog about Pathways for Specialty Care Coordination and Integration in Population-based Models.

Read about the CMS Innovation Center’s new strategic direction, announced in 2021.

Originally posted on: August 14, 2023

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