What is Care Coordination and Why Does it Matter?

Necessity is often seen as the mother of invention. In the healthcare industry, necessity has led to a number of improvements that we take for granted – the carnage of the First World War led to significant advances in prosthetics, cosmetic and reconstructive surgery, germicide, and the X-ray, for example. One-hundred years later, the Affordable Care Act (ACA) has revolutionized the industry once again, as incentives and penalties written into the law have led to a number of new practices and methodologies to improve care.

Effectively Coordinating Care

The aptly named care coordination is one significant improvement brought about by the ACA. The ACA incentivized healthcare providers to examine their current models and find ways to deliver care more efficiently, which would in turn cut costs for consumers. This led to the development of care coordination programs, as they were seen as a way to increase the effectiveness of patient care by streamlining communication and information gathering within treatment teams.

Semi-officially, care coordination is defined as “the the deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of healthcare services,” according to researchers from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. There is a lack of consensus regarding exactly what a care coordination effort should include. However, any effective program should bridge gaps that exist along the “care pathway.”

A care pathway should take into account the idea of continuous care, which, to keep with the metaphor, would be an extension of the pathway. The patient would be able to receive treatment and guidance whether at their home, from the family doctor, via specialists and the emergency room/hospital. This is what a good care coordination plan will do: it will ensure a continuity of care across multiple providers, facilities, etc. – it extends the care pathway.


Data is one way to bring about a positive change for patient outcomes. Care coordination teams may use patient information “to guide the delivery of safe, appropriate, and effective care,” according to the Agency for Healthcare Research and Quality. The agency outlined how care coordination approaches include teamwork, care management, health information technology, and medication management, among other activities.

Communication and Care Coordination

Any care coordination program is successful because of the increased communication both between members of a care team and between medical professionals and their patients. One great example of this type of collaborative approach was at the AtlantiCare Special Care Center in New Jersey. The organization centered their program around multidisciplinary teams, weekly care meetings, and increased collaboration to deliver more targeted care.

Previously, there was a siloed approach within the care model, as doctors and nurses didn’t have the time or resources to effectively track and share information. Patients also felt out of the loop, so it made sense for providers – spurred on by the ACA incentives – to eliminate this fragmentation of care and communication.

Since a lack of communication was previously an issue in the industry, a team of doctors and researchers (affiliated with Emory University, UNC Chapel Hill and University of Colorado) examined new care coordination efforts at several hospitals around the country. Their research, published in the Journal of General Internal Medicine, identified the methodologies that were working, and what challenges existed. The research team found that successful care coordination efforts increased direct access between team members, improved information exchange through shared electronic records, clearly defined accountability and enhanced interpersonal relationships.

Chronic Illness and Care Teams

One type of patient that was targeted during the development of care coordination programs was individuals who experience chronic illnesses. Given that these patients need more frequent care and check-ins with medical professionals, it made sense to bolster the support system and technology framework that was available to these individuals.
In Reducing Care Fragmentation: A Toolkit for Coordinating Care, The Commonwealth Fund studied the impact and market for care coordination programs and similar ventures. Patients with chronic illnesses would benefit from “additional, but less clinically sophisticated, follow-up and support for self-management by telephone or e-mail,” according to the research. By applying the latest technology to this model, a care worker could keep better tabs on these patients with chronic illness, and easily share this information with the rest of the care team.