carecoordination

Care coordination is a deliberate, systematic approach to organizing patient care activities and sharing information among all participants involved in a patient's care to achieve safer and more effective outcomes. It often focuses on individuals with complex or chronic needs and involves clinicians, patients, families, and community or social services working together across settings such as primary care, specialists, hospitals, and home care.

Key components include comprehensive assessment, individualized care planning, clear communication, timely information exchange, medication reconciliation, and scheduled follow-up. The process emphasizes preventing gaps in care during transitions, such as hospital discharge or changes in care settings, and aims to align care goals with patient preferences.

Roles such as care coordinators, case managers, nurse navigators, social workers, and primary care teams coordinate tasks. Care coordination is a core element of models like the patient-centered medical home and some accountable care organizations, supported by health information technology, interoperability standards, and shared care plans.

Properly implemented care coordination can reduce duplicate tests and adverse events, improve adherence and satisfaction, and lower avoidable hospitalizations and overall costs. Measurement often includes process metrics (care plan existence, timely follow-up) and outcomes (readmission rates, emergency department visits, patient-reported outcomes).

Challenges include fragmented health systems, data privacy concerns, inconsistent reimbursement, staffing shortages, and barriers to patient engagement. Social determinants of health and disparities may shape access to coordinated care, requiring tailored strategies and community partnerships.