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.
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.
