A Program of
Southwestern Colorado
Area Health Education Center

701 Camino del Rio, Suite 316
Durango CO 81301
(970) 426-4284
(970) 426-4285

What Is Care Coordination?

Care coordination is the collaboration between primary care providers, medical specialists, social workers, nurses, and physical therapists to achieve the best health outcomes for a group of patients—most cost-effectively. Care coordination bridges gaps in the health care system. It helps patients become more satisfied with the care they receive to meet their health goals.


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The official definition of care coordination from the Agency of Healthcare Research & Quality (AHRQ, 2015): Care coordination is the deliberate organization of patient care activities and information sharing among all of the participants concerned with a patient’s care to achieve safer and more effective care (AHRQ, 2015).

Regionally, we understand care coordination as a complex phenomenon that occurs at multiple levels. Care coordination is the deliberate collective action across multiple organizations and agencies to achieve better population health outcomes through appropriate, culturally-acceptable, and cost-effective integration of physical, mental/behavioral health, and social services. Care coordination is attainable through a multidisciplinary and team-based approach to chronic disease management, which includes the patient and family.

Care coordination tasks include

  • assessing patient needs and goals
  • facilitating transitions in care
  • creating a proactive care plan
  • monitoring and followup, including responding to changes in patients’ needs
  • supporting patients’ self-management goals
  • linking to community resources and
  • working to align resources with patient and population needs.