Care coordination is one of the most powerful tools in healthcare. If designed and led well,, it can have a significant impact on patients, families, communities, health system financial health, quality metrics, and provider and staff satisfaction. A well-run program can impact Primary Care and Specialty service lines. We are going to explore some of the essential components and wins on which you could materialize.

One of my favorite projects was partnering with an organization to initially develop a care coordination program for primary care. We developed a training program and ongoing support/development for the nurses and social workers to prepare them to work collaboratively, identify barriers, determine discharge criteria for the program, and document, along with being partners to the rest of the team. We also integrated both pharmacy support and behavioral health support to ensure that the patient was receiving the holistic care that they desired/needed. 

  We also created the process of identifying patients who needed this extra support, creating the pathway for these patients to promote the best outcomes, determining caseloads, assessments, care plans, and other forms, tracking the outcome process, and gaining feedback to improve continuously.  Once that program was launched, we went to several specialties to define their needs and develop a program for them to address the needs of many patients with chronic or terminal diseases.  We developed some plans to help offset some of the cost of this program also, which was a bonus for everyone.  One of the keys was to have support from our data analyst team so we could track the decrease in Hospitalizations, ED visits, Urgent Care visits, and time spent addressing multiple crises for these patients.

Care coordination is a truly valuable program that thoroughly assesses a patient’s physical, mental, social, and financial status.  It is one of the best tools that helps struggling patients meet goals.  The first step is to understand is whether the patient, family, and healthcare providers all have the same goal.  If the patient’s goals are quite different or there are multiple obstacles in reaching them, many times these patients get labeled as noncompliant.   A complete assessment, establishing mutual goals, and developing those interventions in a collaborative method will have the best results. 

Creating this plan with all participants concerned with a patient’s care will achieve safer and more effective care. The process of care coordination includes the following steps:

1. Assessment and Planning:

   – Evaluate patient needs, preferences, and health status.

   – Partner with patients to agree on mutual goals for their health and quality of life

   – Develop a comprehensive care plan tailored to the individual in partnership with the other care team members.

2. Communication:

  – Have an initial meeting with the patient and family, if appropriate, to review goals, interventions to accomplish those goals, and meeting/visit schedule.

   – Ensure continuous communication between healthcare providers, patients, and their families.

   – Use secure and efficient channels to share information.

  –  Gain feedback from patients, team members, and family to discuss progress, challenges, etc.

3. Resource Allocation:

   – Identify and allocate the necessary resources for the patient’s care.

   – Identify resources that will enhance quality of life when appropriate.

   – Ensure that services and support are available when needed.

4. Monitoring and Follow-up:

   – Regularly review the patient’s progress towards their goals and update the care plan as necessary.

   – Follow up on any changes in the patient’s condition or needs.

5. Transition Management:

   – Coordinate care during transitions between different care settings (e.g., from hospital to home).

   – Ensure that all relevant information is transferred accurately and promptly.

6. Patient and Family Involvement:

   – Engage patients and their families in the decision-making process.

   – Provide education and support to help them manage the patient’s health effectively.

Benefits of Care Coordination

1. Improved Health Outcomes:

   – Reduces medical errors and adverse events.

  – Decreases cost for patients and organizations by early symptom identification, education of patients and families, identification of barriers to reaching goals, and improving quality of life.

   – Ensures that patients receive timely and appropriate care in the best setting.

2. Enhanced Patient Experience:

   – Improves patient satisfaction by making care processes much smoother and more responsive to their needs and true goals.

   – Encourages full patient engagement both in planning and in developing the plan of care which results in better adherence to treatment plans.

3. Reduced Healthcare Costs:

   – Decreases unnecessary hospital admissions, readmissions, ED visits, and extensive crisis management.

   – Minimizes duplication of services and redundant tests.

  – Decreases complications due to errors in medication reconciliation.

  – Partners with Pharmacy colleagues to assure that the medication regime does not create complications for the patient that prevent them from reaching healthcare goals.

4. Better Resource Utilization:

   – Optimizes the use of healthcare resources by ensuring they are used efficiently.

   – Identifies community resources to help support the patient.

   – Coordinates care to avoid gaps and overlaps.

5. Increased Efficiency:

   – Streamlines communication and collaboration among healthcare providers.

   It decreases the burden on nurse triage and education, UC, and ED resources and the frequency of messages to the provider to resolve these healthcare crises.

   – Enhances the efficiency and cost management of care delivery systems.

6. Support for Chronic Disease Management:

   – Provides comprehensive and continuous care and education for patients with chronic conditions or terminal conditions.

   – Helps manage and monitor long-term health issues effectively.

  – Establish a routine for goals of care conversations so that when the patient needs a higher level of services, those conversations are easier and more productive.

One of the stories that I share with healthcare leaders is the story of Mary – a fictional name.

Mary had several co-morbidities and was calling her clinic at least once per day, many days several times.  She had 18 ED visits in the previous 6 months and 4 hospitalizations in the same amount of time.   She was perceived as non-compliant but most of her different providers. 

After completing a full assessment, having goals of care conversations, speaking with her providers, and having a brief care conference, a plan of care was developed together.    In the following 12 months, she had 1 ED visit, 1 hospitalization, and only a few calls to the office.  I would love to share the rest of the story with you, but you can see the cost savings, in addition, she was able to meet all three of her quality-of-life goals we had helped her define a year prior.  

Overall, care coordination is essential for achieving high-quality, patient-centered care, particularly for individuals with complex health needs. It is a model for developing a true partnership between the patient and the healthcare team to accomplish the patient’s healthcare goals.

Few programs add more value to a health system and the providers while providing a truly patient-centered healthcare experience that addresses all aspects of their recovery or disease management and gives them the best quality of life possible. 

We would love to meet with you and see if we can partner to either enhance your current program or support you in developing a comprehensive care coordination/management program. 

Reach out any time at:  to set up a discovery call at no charge.