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


Stefanacci RG. Care coordination today: what, why, who, where, and how? Annals of Long-Term Care: Clinical Care and Aging. 2013;21(3):38-42.


Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD

Series Editor: Barney S. Spivack, MD, FACP, AGSF, CMD

Historically, “good” clinical geriatric care was pictured to consist of solo physician practitioners tending to the needs of their older patients across all care settings, from home, to hospital, to long-term care. This picture has evolved, and today’s “best” practice includes an interdisciplinary care team (IDT). This is in part because of the complexities of providing geriatric care, particularly in today’s healthcare environment, which requires balancing an increasing number of clinical, logistical, financial, and regulatory variables. There has been widespread interest in developing solutions that overcome these challenges to improve the effectiveness and efficiency of the healthcare system. This task is especially vital given the complexity and resource constraints facing Medicare as baby boomers age and the federal budget constricts. 

One proposed solution to the problem is care coordination, a strategy the Institute of Medicine has deemed to be instrumental for optimizing care, as it has the potential to reduce cost and improve outcomes for all populations in all healthcare settings. However, the most impressive outcomes with care coordination have been observed for high-risk populations whose complex health issues involve costly treatments and often result in repeated hospitalizations. Because of the importance of care coordination, it is a required element of the Patient-Centered Medical Home (PCMH) model. In the PCMH model, coordination is meant to ensure that care is organized across all elements of the broader healthcare system, including specialty care, hospitals, home healthcare, and community services and supports. This article examines many questions regarding care coordination and reviews issues surrounding its implementation. 

What Is Care Coordination? 

Care coordination is sometimes used synonymously with case management or care management, but each of these terms has a slightly different focus. According to the National Quality Forum, care coordination is “a function that helps ensure that the patient’s needs and preferences for health services and information sharing across people, functions, and sites are met over time,”1 whereas the Taber’s Cyclopedic Medical Dictionary defines case management as an “individualized approach to coordinating patient care services for individuals with complex healthcare needs or chronic medical problems.”2 Blue Cross describes case management as “coordination of services to help meet a patient’s healthcare needs, usually when the patient has a condition requiring multiple services from multiple providers,” and it defines care management as “healthcare services and programs designed to help individuals with certain long-term conditions better manage their overall care and treatment.”3 As these definitions show, although care coordination, case management, and care management have similar functions and objectives, their approaches are different. Care coordination is meant to be more inclusive as a patient- and family-centered approach for care delivery, whereas case management and care management have a more structured, healthcare-environment–focused approach for care delivery. Regardless of the approach, coordination of care is being viewed as a foundation in accountable care organizations (ACOs) and in other emerging models of care as a means of producing higher quality care at a lower cost for patients and the system as a whole.

Why Is Care Coordination Needed?  

Care coordination is needed for numerous reasons. First and foremost, lack of coordination can be unsafe, even fatal. When abnormal test results are not communicated correctly between multiple providers or between providers and patients, when prescriptions are issued by multiple physicians and there is unawareness of the medications the patient is already taking, and when primary care physicians (PCPs) do not receive hospital discharge plans for their patients, the risk of poor patient outcomes is high. These are just a few of the scenarios that may arise from uncoordinated care. 

Second, as noted by the American College of Physicians, uncoordinated care is more costly for patients and the healthcare system, as it increases duplicate services, increases the risk of preventable hospital admissions and readmissions, and contributes to overuse of more intensive procedures.4 On average, patients who receive uncoordinated care are estimated to pay 75% more for their healthcare services than matched patients with coordinated care.5 Owens6 suggested that enhanced care coordination could reduce 35% of costs. Because of the recognized impact of care coordination, the Patient Protection and Affordable Care Act invokes care coordination throughout its provisions to improve the quality of care and control costs to transform the healthcare-delivery system. Care coordination is also a key feature of evolving ACOs, which seek to integrate effective care coordination with accountability, incentives, and quality measurement.

There is growing evidence that care-coordination programs work, are beneficial in various organizational settings, and can be supported through different financial means. Mathematica Policy Research7 found several studies of at least moderate internal validity that showed improvements in quality of life for persons under care-coordination programs. Claiborne described a care-coordination program for stroke survivors that was supported by mixed funding sources.8 Compared with persons receiving regular care (n=12), the coordinated-care group (n=16) showed significantly improved quality of life, decreased depressive symptoms, and increased adherence to self-care practices. In this program, social workers coordinated a wide range of medical and social services using a standardized, problem-solving care-coordination model. 

In 2010, Marek and colleagues9 reported improved activities of daily living and a decrease in pain and other symptoms for 55 nursing-home–eligible elders participating in the Aging in Place program, which was financed by both Medicare and Medicaid. In the program, care coordination was provided by specially trained nurses who operated in a fully integrated model, managing a broad range of medical and long-term care services and supports. Comprehensive needs assessment and periodic home visits were also elements of this care-coordination intervention.

Who Oversees Coordinated Care? 

In today’s healthcare environment, the IDT is tasked with navigating healthcare challenges and coordinating care through all settings, with the dual objective of improving outcomes for patients and sparing already taxed healthcare system resources, such as by reducing the frequency of hospital admissions and services. To realize the IDT’s role in care coordination, it is important to understand who comprises the IDT and each member’s role in this endeavor. 

Today’s IDT can consist of nursing staff, pharmacists, social workers, physician extenders (ie, nurse practitioners and physician assistants), and therapists. With so many different persons potentially involved in any patient’s care, it is easy to see how challenging care coordination can be, but it is also apparent that these teams have the potential to deliver tremendous results because of their combined expertise. For care coordination to be optimized, it is essential for every member of the team to know his or her role and the role of the other members and to work together. 

Although all IDT members play a role in care coordination, nurses take center stage in this arena, often becoming the care coordinators. This is not surprising given care coordination is considered a professional competency of all registered nurses. As a result, these healthcare professionals are generally the ones tasked with coordinating communication and healthcare efforts between the other healthcare members and with patients to improve patient care across healthcare settings and populations. In the American Nurses Association position statement, The Nurse’s Essential Role in Care Coordination,5 registered nurses are noted to be integral to achieving care-coordination excellence. This stance is also taken by a National Coalition on Care Coordination white paper, which describes the roles and benefits of nursing in the care-coordination process and provides evidence of the centrality of registered nurses to healthcare that is patient-centered, high-quality, and cost-effective.10

Payers also play a key role in the care-coordination process, as they provide care-coordination fees to the ACO to support the work of the IDT teams. Both government (Medicare/Medicaid ACO models) and private payers (managed care organizations) promote and contract with ACOs and provide them with care-coordination funds. These funds can be paid concurrently and are an important part of cash flow for ACOs.

Recently, the Centers for Medicare & Medicaid Services issued a policy to pay physicians to coordinate patients’ care in the 30 days following a hospital or skilled nursing facility stay.11 This recognizes the work of community physicians in treating patients following a transition of care and strives to ensure better continuity of care and reduce readmissions. Physicians can bill one of two codes, depending on the complexity of the service provided: the higher-level billing code requires a face-to-face visit with the patient within 1 week of discharge, and this code is expected to provide a reimbursement of $230; the lower-level code, which requires a face-to-face visit within 2 weeks, is expected to provide a reimbursement of $160. These additional funds could be used to support the addition of care-coordination staff.

Where Does Care Coordination Occur? 

Care coordination can occur in a variety of settings, as IDT members can exist as independent practitioners; employees of healthcare plans, which is especially relevant in special needs plans; or as part of a provider-based organization. It is increasingly common for IDT members to be employed by ACOs or similar providers rather than the traditional arrangement through health plans and healthcare systems. But it sometimes remains unclear which entity is best suited for employing the care coordinator to optimize his or her level of integration into the practice. 

Today, because the PCP’s office still represents the base for most outpatient care, it can provide an ideal site for care coordination. In one pilot program,a national insurer placed nurse case managers in PCPs to work alongside providers in their offices to help manage patients’ conditions.12 This pilot found that having case managers embedded at physicians’ offices increased their ability to effectively manage patient care, compared with typical telephone-based approaches. It is thought that this was the result of their enhanced ability to collaborate with physicians and other staff via regular, face-to-face contacts and establish trust over time. Case managers also benefited from working in these data-rich environments, as this facilitated their ability to track performance on agreed-upon quality measures. The reported benefits included improved care processes, some improvements in care outcomes, and fewer hospitalizations.

Outside of the PCP office, another site for care and care coordination is the home. An in-home health consultation program, which was provided by advanced practice nurses and guided by the principles of health promotion, empowerment, partnership, and family-centeredness, has been reported to be effective in reducing adverse health outcomes, such as falls, acute events, and hospitalizations.13 While the care coordination based in the PCP office and home can stand alone, a preferred approach may be combining home care with office-based care. This has occurred in the Guided Care® program.14 Guided Care is proposed as a solution to the growing challenge of caring for older adults with chronic conditions and complex health needs. Guided Care nurses partner with physicians and other healthcare providers in primary care to provide coordinated, patient-centered, cost-effective care to persons with multiple chronic conditions. The nurse conducts in-home assessments, facilitates care planning, promotes patient self-management, monitors conditions, coordinates the efforts of all care professionals, smoothens transitions between sites of care, educates and supports family caregivers, and facilitates access to community resources.

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
Healthcare Imperative: Lowering Costs and Improving Outcomes, Workshop Series Summary
. Washington, DC: National Academy Press; 2010:131-140.

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.


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