Care coordination means different things to different people, and no universal definition has emerged. Over 40 reports of the term “care coordination” were identified in a recent systematic review. 2 The authors of the systematic review combined the common elements of many definitions to create one working definition for use in determining reviews of interventions in the vicinity of care coordination, resulting in a purposefully broad definition: “Care coordination is the intentional organization of patient care activities between two or more participants (including the patient) involved in the patient’s care in order to facilitate the appropriate delivery of health care services. Organizing care entails the gathering of personnel and other resources required to carry out all required patient care activities, and is frequently managed through the exchange of information among participants responsible for various aspects of care.” They noted that for some purposes, other definitions may be more appropriate. This lack of agreement is unsurprising given the many people involved in care coordination.
Without a consensus definition, we provide a visual depiction (see Figure 1) and scenarios to help illustrate care coordination. Some Atlas users may find this helpful visual definition, while others may find it less so. A recent monograph on cancer care quality includes several additional examples of care coordination. 3
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The central goal of care coordination is depicted in the diagram’s centre. The coloured circles represent potential participants, settings, and data relevant to care pathways and workflow. Care Coordination is represented by the blue ring connecting the coloured circles—anything that bridges gaps (white spaces) along the care pathway (i.e., care coordination activities or broad approaches hypothesized to improve care coordination). To provide coordinated care for a given patient at a given time, bridges or rings must form across the applicable circles and through any gaps within a given process.
Care Coordination Perspectives
Care coordination successes and failures will be perceived (and possibly measured) differently depending on the perspective: patient/family, health care professional(s), or system representative (s). Consideration of views from these three potentially disparate perspectives is likely to be critical for comprehensively measuring care coordination.
From the standpoint of the patient or family. Care coordination is any activity that helps ensure that a patient’s needs and preferences for health services and information sharing are met across people, functions, and sites over time. 4
Coordination failures affect patients, their families, and other informal caregivers, especially at transition points. Transitions in responsibility and information flow can occur between healthcare entities (see definition under “additional terms”) and over time. Patients perceive failures as excessive levels of effort required on their part or the part of informal caregivers to meet care needs during transitions between healthcare entities.
The perspective of a Health Care Professional(s). Care coordination is a patient- and family-centred, team-based activity that assesses and meets patients’ needs while assisting them in navigating the healthcare system effectively and efficiently. Clinical coordination entails deciding where to send the patient next (e.g., specialist sequencing), what information about the patient must be transferred between healthcare entities, and how accountability and responsibility are managed among all healthcare professionals (doctors, nurses, social workers, care managers, supporting staff, etc.). Care coordination fills gaps in meeting patients’ interrelated medical, social, developmental, behavioural, educational, informal support systems, and financial needs to achieve optimal health, wellness, or end-of-life outcomes based on patient preferences. 5
Coordination failures are noticed by health care professionals when a patient is directed to the “wrong” location in the health care system or has a poor health outcome as a result of poor handoffs or inadequate information exchanges. They also need to improve the excessive effort required to achieve necessary levels of coordination during transitions among healthcare entities.
The perspective of System Representative(s). Care coordination is the responsibility of any care system (for example, an “accountable care organization [ACO]”) to integrate personnel intentionally, information, and other resources required to carry out all required patient care activities between and among care participants (including the patient and informal caregivers). Care coordination aims to make it easier to deliver appropriate and efficient healthcare services within and across systems.
Failures in coordination that impact the system’s financial performance will almost certainly motivate corrective actions. When a patient suffers a clinically significant mishap as a result of care fragmentation, system representatives will perceive a failure in coordination. 6
Additional Conditions. Additional terms related to care coordination are defined further below.
Entities involved in health care. Healthcare entities are distinct units of the healthcare system that play different roles in care delivery. Who those units are will be determined by the context and perspective. As an example:
From the perspective of the patient and family, entities are most likely individual healthcare providers with whom the patient and family interact, such as nurses, physicians, and support staff.
From a healthcare professional’s perspective, entities can be individual members of a workgroup, such as nurses, physicians, and support staff in a specific clinic. They could also be provider groups like a primary care practice, a specialty practice, or an urgent care clinic.
Entities will most likely be groups of providers acting as a unit, such as medical units in a hospital, hospitals as a whole, specialty clinics within an integrated system, or different clinical settings within the health care system as a whole (i.e., ambulatory care, inpatient care, emergency care).
Transition points. When information about or accountability/responsibility for some aspect of a patient’s care is transferred between two or more healthcare entities, or when one entity maintains it over time, a transition occurs. Information and responsibility are frequently (or should be) transferred together.
It may be helpful to consider two broad categories of transitions:
Transitions between healthcare entities. Changes in information and responsibility:
Members of a single care team (receptionist, nurse, physician)
Among patient care teams
Patients/informal caregivers versus professional caregivers
Across environments (primary care, specialty care, inpatient, emergency department)
Among health-care organizations
Transitions occur over time. Changes in information and responsibility:
In between care episodes (i.e., initial visit and follow-up visit)
Across the lifespan (for example, pediatric developmental stages, women’s changing reproductive cycles, and senior care requirements)
Throughout the illness’s progression and changing levels of coordination
Figure 1 shows the Care Coordination Ring.
Figure 1 shows the Care Coordination Ring. Choose from the options below for a text description.
[D] Choose Text Description.
The central goal of care coordination is depicted in the diagram’s centre. The coloured circles represent some possible care pathways and workflow participants, settings, and information. Care Coordination is represented by the blue ring connecting the coloured circles—specifically, anything that bridges gaps (white spaces) along the care pathway (i.e., care coordination activities or broad approaches hypothesized to improve care coordination). See Figure 2). Care coordination successes and failures will be perceived (and possibly measured) differently depending on the perspective: patient/family, health care professional(s), or system representative (s).
As illustrated by the scenarios below, the level of care coordination need will increase as system fragmentation (e.g., wider gaps between circles), clinical complexity (e.g., more processes on a ring), and patient capacity for participating effectively in coordinating one’s care increase. The level of need is determined by something other than time or patience. The story of care coordination is likely to be important in tailoring interventions and evaluating their effectiveness.
Situation 1. Mrs Jones is a 55-year-old woman in good health. Dr I. Care, her primary care provider, sees her once a year for a routine physical. Dr Care works in a primary care clinic with an electronic medical record (EMR) system and laboratory and radiology services on-site. Care ordered several blood tests to evaluate Mrs Jones’ cholesterol and triglyceride levels during her annual physical. Mrs Jones also mentioned that she still has pain in her ankle from a previous sprain. Dr Care requested an x-ray. Dr Care determines Mrs Jones’ cholesterol is high after receiving the blood test results via the electronic medical record system and prescribes medication. She sends the prescription directly to the pharmacy using an EMR link. She receives an electronic notification that the x-ray reveals no fracture. Mrs Jones is contacted and directed to a nearby physical therapy practice. Mrs Jones goes to the pharmacy to get her medication and then calls the physical therapist to make an appointment.
Visual Complexity: Scenario 1 Low Patient Capacity: Low Fragmentation: High Care Coordination Minimal requirement
Scenario 1: Text Description (see below).
[D] Choose Text Description.
Scenario 2: Mr Andrews, 70, has congestive heart failure and diabetes. He walks with a cane and has recently experienced some mild memory problems. Dr Busy, his primary care physician, is part of a small group of physicians. The primary care clinic has a laboratory, but radiology tests are sent to a nearby radiology centre. Mr Andrews also sees nephrologist Dr Kidney and cardiologist Dr Love. Both specialists work for a specialty group practice unrelated to Dr Busy’s clinic. Their on-site laboratory, radiology clinic, and pharmacy round out their specialty practice after his appointments with Drs. Kidney and Love, Mr Andrews has his prescriptions filled at the specialty clinic pharmacy, and he picks up medications prescribed by Dr Busy at a pharmacy near his home. Mr Andrews has a daughter who lives in the neighbourhood but works full-time. Because he has difficulty getting to the grocery store, he receives meals delivered to his home five days a week by a meals-on-wheels senior support service. His daughter has hired a caregiver to assist Mr Andrews with household tasks three days a week for two hours.
Mr Andrews appeared very ill during a recent meal delivery, according to the program staffer. Mr Andrews was taken to the emergency department after he called an ambulance. He was admitted after being diagnosed with a congestive heart failure exacerbation. During his initial evaluation, the admitting physician inquired about the medications Mr Andrews was taking, but the patient was unable to recall what they were or the dosages. The hospital team’s physician contacted Dr Busy, who provided a medical history and a list of medications. Dr Busy noted that Mr Andrews’s dosing may have changed following a recent appointment with Dr Love. Dr Busy also mentioned that Mr Andrews might be missing medication due to his forgetfulness. He gave the hospital team Drs. Love and Kidney’s contact information. He also requested that upon Mr Andrews’ discharge, a record of his hospital stay be sent to his office.
One week later, Mr Andrews was released from the hospital. Before he left, the nurse went over important information with him and his daughter, who was driving him home. They discussed several new prescriptions and the specifics of a low-salt diet. She instructed him to make an appointment with his primary care physician within two days and to see his cardiologist within two weeks. Mr Andrews was exhausted, so his daughter picked up the prescriptions from a pharmacy near the hospital rather than the one he usually visits.
Visual Complexity in Scenario 2: Moderate Fragmentation: High
Patient Low Care Capacity Extensive coordination is required.
Mr Andrews is the second scenario. This diagram is an extension of Figure 1 and depicts a triangle surrounded by a ring and a series of circles. The circles are labelled with different participants, settings, and types of information related to Mr Andrews’ need for care coordination, which is detailed in Scenario 2. The circle labels include medical history, test results, nephrology, cardiology, inpatient care, patient/family education and support, informal caregivers, medications/pharmacies, community resources, and phlebotomy.
McDonald KM, Sundaram V, Bravata DM, and colleagues. Coordination of care. Shojania, K.G., McDonald, K.M., Wachter, R.M., and Owens, D.K., eds. A critical examination of quality improvement strategies for closing the quality gap. Vol. 7. Technical Review 9 (prepared by the Stanford-UCSF Evidence-Based Practice Center under contract No. 290-02-0017). Agency for Healthcare Research and Quality, Rockville, MD, June 2007. Publication No. 04(07)-0051-7 by the AHRQ.
3 Rodgers AB, Taplin SH. Addressing the interfaces of primary and oncology-related subspecialty care to improve cancer care quality. Journal of the National Cancer Institute Monogr. 2010;40:3-10.
4 Information adapted from the National Quality Forum.
5 Information adapted from Antonelli RC, McAllister JW, Popp J. A multidisciplinary framework for making care coordination a critical component of the pediatric healthcare system. The Commonwealth Fund, New York, 2009.
6 Information adapted from McDonald KM, Sundaram V, Bravata DM, et al. Coordination of care. Shojania, K.G., McDonald, K.M., Wachter, R.M., and Owens, D.K., eds. A critical examination of quality improvement strategies for closing the quality gap. 9th Technical Review (Prepared by Stanford-UCSF Evidence-Based Practice Center under contract No. 290-02-0017). Agency for Healthcare Research and Quality, Rockville, MD, June 2007. Publication No. 04(07)-0051-7 by the AHRQ.
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