Skip to main content

Care Coordination Teams: A Managed Care Approach


Tori Socha

Minneapolis—Care coordination has been defined by the Agency for Healthcare Research and Quality as the “deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of healthcare services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care.”

At a managed care essentials session at the AMCP meeting titled Defining Care Coordination Teams: Pharmacists, Nurses, and Physicians in Managed Care, attendees heard from a pharmacist and 2 nurses on this emerging concept of patient care. Brieana Cox Buckley, PharmD, MHP, began her presentation by providing data on the effectiveness of care coordination interventions. Evidence of patient benefit has been found in systematic reviews cited by Dr. Buckley. In a 2003 study, multidisciplinary palliative care teams significantly improved patients’ pain scores and other symptoms. A 2005 study found that diabetes disease management programs reduced hemoglobin (Hb) A1c by a mean of 0.5%; the programs that were associated with the greatest reduction involved pharmacists counseling patients and combined physician and patient interventions. A mental health study found that mental health case management was effective in reducing rehospitaliztions; patients receiving intense case management (case managers had a case load of <15 patients at any time) were 30% less likely to be rehospitalized.

The components of care coordination include assessing the patient to identify possible coordination challenges; developing a care plan; identifying the participants in the care plan and specifying the role of each participant; communicating the plan to the patients and all other participants; monitoring and adjusting care as needed; and evaluating the outcomes. Common support features identified by Dr. Buckley included information systems (electronic medical record, personal health record, and continuity of care record), tools (standard protocols, evidence-based guidelines, routine reporting and feedback), techniques designed to mitigate interface issues (multidisciplinary teams for specialty and primary care, and use of the medical home model to support information exchange at interfaces), and a redesign of the current system of reimbursement (paying physicians for time spent coordinating care, reducing barriers that limit access to a care coordination plan, such as lack of insurance, underinsurance, and physical distance from treatment facilities).

Dr. Buckley continued by noting opportunities for pharmacists in care coordination: providing direct patient care services, optimizing drug regimens to reduce adverse effects, ensuring patient access to community services, assisting patients with transitions of care, providing medication therapy management services, and proposing effective cost-management strategies. She concluded her presentation with examples of care coordination, including a high narcotic utilizers team charged with identifying and coordinating care for members with at-risk behaviors, and working closely with the patient to offer crisis intervention if needed; a diabetes incentive team, working system-wide to decrease members with a persistently elevated HbA1c (>8. 0%) by offering incentives and rewards based on the extent of patients’ participation; and patient-centered medical homes, providing coordinated care and enhanced patient access to care. Other areas of collaboration outlined by Dr. Buckley were care process models, primary care incentive programs, disease management reports, and preauthorization referrals to case management for patients with hepatitis C, asthma, or with high-risk pregnancies.

Nurse Case Managers

Stefany H. Almaden, RN, MS, CCM, spoke on the role of the nurse case manager in care coordination. She said that healthcare reform efforts have stressed the growing emphasis on chronic disease care management, the best use of available healthcare resources, and safe transitions of care management. A coordinated care team can have an impact on patient care by shortening the term of acute care, examining gaps in care, and focusing on care transitions. Ms. Almaden continued by outlining the emerging role of nurse case managers, saying that nurses in managed care focus on medication compliance, and moving from a “nursing process to a dynamic care plan that is communicated with the care coordination team and the patient/caregiver.” She then presented 3 scenarios where the nurse case manager had an integral role in care coordination. She concluded by describing the 6 Institute of Medicine goals for care improvement—safe, patient-centered, effective, efficient, timely, and equitable. She said that those goals are still important and achievable with increasing emphasis on the care coordination team.

Carrie Ann Marion, RN, CCM, described the goals of care coordination as providing the right healthcare services, in the right order, at the right time, in the right setting, by the right providers. Elements of care coordination include involvement of the appropriate participants in patient care, interdependence of participants, information exchange accessibility, and knowledge about resources and the role of each participant. She described the ideal patient for care coordination as a person with complex discharge needs, who may have issues with access to care, who may be experiencing gaps in care, who is part of an at-risk population (elderly, disabled, special needs), a patient who is frail or elderly, a patient with multiple chronic conditions, and/or a patient who is a high utilizer of healthcare services.

Ms. Marion continued by noting that models for care coordination vary with the patient population, with payer orientation, and with program goals. For dual-eligible patients with special needs, Medicare requires communication and collaboration among all care coordination team members. The requirements state that a coordinated care plan be in place for all dual-eligible patients. Managed Medicaid programs also stress care coordination for at-risk populations, she added. She concluded by citing some issues associated with implementation of care coordination, including boundary issues, confidentiality issues, the need for standardized tools for assessment, and planning. Other considerations include the costs of care coordination programs, availability of funding, and developing methods to evaluate the effectiveness of the programs.

Back to Top