Care Coordination Today: What, Why, Who, Where, and How?: Page 2 of 2

March 15, 2013

How Can Care Coordination Be Optimized? 

Although care-coordination models vary, they typically make use of case managers, care transition programs, disease management, health information technology, and other resources to effectively manage service delivery and to support patients and providers. By making use of these resources, these models are demonstrating how healthcare can be delivered more smoothly and efficiently, particularly for people with chronic illnesses and complex needs. Although details differ between care-coordination models, the best ones share some common characteristics, including:

• Individuals and families are at the center of care planning and delivery;

• Care continuity extends across medical and nonmedical services and from acute to long-term care settings;

• Strong clinical and organizational support is in place for effectively coordinating care;

• Appropriate payment incentives for coordinating care and integrating benefits are in place; and

• Systems for including the consumer voice in care design and plan governance are enabled.

Because care coordination is particularly important during care transitions, Eric Coleman, MD, MPH, and his team at Care Transitions15 identified four key areas of focus with regard to ensuring patient safety during such occurrences. These are referred to as The Four Pillars®, and they can serve as a basis for both care transitions and care coordination across all the varying settings of care, from the office, to in-patient units, to the home. Coleman’s pillars include the following:

1. Medication self-management. The patient and his or her family are determined to be knowledgeable about the patient’s medications and to have a medication management system in place.

2. Use of a dynamic patient-centered record. The patient or his or her caregiver is provided with a personal health record (PHR; ie, a health record in which health data and information related to the care of a patient is maintained by the patient or caregiver) and he or she understands and uses the PHR to facilitate communication and ensure continuity of the care plan across providers and settings. 

3. Primary care and specialist follow-up. The patient or his or her caregiver schedules and completes follow-up visits with the PCP or specialist physician and is empowered to be an active participant in these interactions.

4. Patient awareness of red flags. The patient or his or her caregiver is knowledgeable about indications that the patient’s condition is worsening and knows how to respond to this.

When care transitions occur, they require particular attention by healthcare providers, as these IDT members are being held responsible for communicating with all of the healthcare providers and agencies involved in a given patient’s care. These responsibilities include reconciling patients’ discharge medications with their previous regimens to lessen the likelihood of adverse drug events, which occur all too often during care transitions.

To enhance care coordination, practice facilitators have been incorporated into some models. These professionals are tasked with assisting practices with coordinating their quality improvement activities and with helping them build capacity for those activities, providing a systems-level approach to improving quality, safety, and implementation of evidence-based practices.16 The Agency for Healthcare Research and Quality (AHRQ) describes a growing body of evidence that supports the concept of practice facilitation as an effective strategy to improve primary healthcare processes and outcomes, including the delivery of wellness and preventive services, through the creation of an ongoing, trusting relationship between an external facilitator and a PCP.17 Practice facilitation activities may focus in particular on helping PCPs become medical homes, but they can also help practices in more general quality-improvement initiatives and redesign efforts. Practice facilitation has a moderately robust effect on evidence-based guideline adoption within primary care. Implementation fidelity factors, such as tailoring ability, the number of practices per facilitator, and the intensity of the intervention, have important resource implications.18 The AHRQ sponsored the development of a “how-to guide” for organizations interested in starting a practice facilitation program aimed at improving primary care.19 The practice facilitation programs described in this guide are designed to work with PCPs on quality improvement activities, with an emphasis on primary care redesign and transformation. The guide focuses on how to establish and run an effective practice facilitation program, and is intended for organizations or individuals who will develop, design, and administer such programs. 

How Can Geriatricians Adopt a Care-Coordination Model? 

Geriatricians who are interested in incorporating care-coordination techniques and staff into their practices can find growing support in the payer and health delivery systems that operate in their areas. According to the Centers for Medicare & Medicaid Services Acting Administrator Marilyn Tavenner, the Medicare ACO program has more than 2.4 million beneficiaries receiving care from providers participating in these important initiatives.20 Nearly all have care-coordination programs and will support PCPs who seek to use care-coordination resources. Many private payers provide “care-coordination” fees to primary care medical homes for the same purpose. As an alternative to practices recruiting and employing care-coordination staff, the ACOs and payers will embed their own care-coordination resources on a part- or full-time basis. 

Once implemented, care-coordination resources need to be introduced to the practice and its patients, new record-keeping systems learned, local support resources used, and other time-consuming tasks undertaken. This requires commitment from the entire IDT—time that is not reimbursable in a fee-for-service model; however, in the long run, care-coordination resources can improve productivity, but financial support from payers or the health system is necessary for most practices, especially smaller practices that already face economic challenges. 

As outlined in a recently published article in Annals of Long-Term Care,geriatricians should also recognize that numerous difficulties may be encountered, even once a coordinated-care model has been established.21 Lack of communication between physicians and case mangers can occur, which has been shown to result in adverse medical events and to increased healthcare costs for older adults receiving home- and community-based long-term care services. To avoid such problems and achieve successful care coordination, open communication between all IDT members must be facilitated and encouraged. Beyond this requirement, care coordination will require:

• Recognition by the entire IDT that care coordination improves the quality of patient care and reduces costs;

• Development of a clear role and responsibility for the care coordinator within the IDT; and

• Obtaining a care coordinator in the most efficient and effective manner through either an ACO or another appropriate entity, such as an integrated delivery system. 

Once all of these steps have been accomplished, care coordination can be successful in protecting older adults as they navigate the increasingly complex healthcare maze.


Care coordination should take a patient- and family-centered approach to ensure that all IDT members are aware of patients’ healthcare needs and preferences. It should also promote effective communication between all IDT members and their patients regarding all care decisions and developments, regardless of site. The best care-coordination model is one in which a patient experiences primary care as delivered by an integrated, multidisciplinary team that explicitly includes at least one staff care coordinator. PCPs can play a role in obtaining a care coordinator either independently or through an ACO or another appropriate entity. Once a care coordinator is involved, this individual should be integrated into the team and all processes as fully as possible to ensure communication and care are optimized. This approach will go a long way in improving outcomes for patients and in reducing unneeded stress for all individuals involved in patient care, including patients and their families. Today’s healthcare environment can certainly benefit from improved patient outcomes and reduced stress.


1. National Quality Forum. NQF-Endorsed™ Definition And Framework For Measuring Care Coordination. Accessed March 3, 2013.

2. Venes D, ed. Taber’s Cyclopedic Medical Dictionary. 21st ed. Philadelphia, PA: F.A. Davis Company; 2009.

3. Blue Links for Employers. Glossary. glossary.html. Accessed March 7, 2013.

4. American College of Physicians Online. Enhance care coordination through the patient centered medical home (PCMH) background. practice/delivery_and_payment_models/pcmh/understanding/pcmh_back.pdf. Accessed February 11, 2013.

5. American Nurses Association. The value of nursing care coordination: a white paper of the American Nurses Association. Published June 2012. Accessed February 11, 2013.

6. Owens MK. Costs of uncoordinated care. In: Yong PL, Saunders RS, Olsen LA, eds. The
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7. Au M, Simon S, Chen A, Lipson D, Gimm G, Rich E. Comparative Effectiveness of Care Coordination for Adults with Disabilities. Mathematica Policy Research. Published July 2011. Accessed February 11, 2013.

8. Claiborne N. Effectiveness of a care coordination model for stroke survivors: a randomized study. Health Soc Work. 2006;31(2):87-96.

9. Marek KD, Adams SJ, Stetzer F, Popejoy L, Rantz M. The relationship of community-based nurse care coordination to costs in the Medicare and Medicaid programs. Res Nurs Health. 2010;33(3):235-242.

10. National Coalition on Care Coordination Statement for Older Americans Act Stakeholder Meeting Subcommittee on Primary Health and Aging and the Committee on Health, Education, Labor, and Pensions. United States Senate. New York Academy of Medicine. Published August 25, 2011. Accessed February 11, 2013.

11. Centers for Medicare & Medicaid Services. Payments to primary care physicians increase in 2013: physician fee rule part of new drive to reward savings, foster collaboration. counter=4469&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date. Published November 1, 2012. Accessed February 11, 2013.

12. Hostetter M. Quality matters case study: Aetna’s embedded case managers seek to strengthen primary care. The Commonwealth Fund. Published August/September 2010. Accessed February 11, 2013.

13. Imhof L, Naef R, Wallhagen MI, Schwarz JS, Mahrer-Imhof R. Effects of an advanced practice nurse in-home health consultation program for community-dwelling persons aged 80 and older. J Am Geriatr Soc. 2012;60(12):2223-2231.

14. Johns Hopkins Bloomberg School of Public Health. Guided care. Comprehensive primary care for complex patients. Accessed February 11, 2013.

15. Coleman EA. The Care Transitions Program: healthcare services for improving quality and safety during care hand-offs. Accessed February 11, 2013.

16. Taylor EF, Machta RM, Meyers DS, Genevro J, Peikes DN. Enhancing the primary care team to provide redesigned care: the roles of practice facilitators and care managers. Ann Fam Med. 2013;11(1):80-83.

17. US Department of Health and Human Services, Agency for Healthcare Research and Quality. Implementing the PCMH: practice facilitation. Accessed March 7, 2013.

18. Baskerville NB, Liddy C, Hogg W. Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med. 2012;10(1):63-74.

19. US Department of Health and Human Services, Agency for Healthcare Research and Quality. Developing and running a primary care practice facilitation program: a how-to guide. Accessed March 7, 2013.

20. US Department of Health and Human Services. HHS announces 89 new accountable care organizations. Published July 9, 2012. Accessed February 11, 2013.

21. Page TF, Brown EL, Ruggiano N, Roberts L, Hristidis V. Improving care delivery using health information technology in the home care setting: development of the home continuation care dashboard. Annals of Long-Term Care. 2012;20(12):26-30.