Care coordination is a patient-centered, team-based activity designed to assess and meet the needs of patients while helping them navigate effectively and efficiently through the healthcare system. It involves deliberately organizing patient care activities and sharing information among all participants concerned with a patients care to achieve safer and more effective care. The main goal of care coordination is to meet patients needs and preferences in the delivery of high-quality, high-value healthcare.
Some key elements of care coordination include:
- Communicating and sharing knowledge
- Helping with transitions of care
- Assessing patient needs and goals
- Creating a proactive care plan
- Monitoring and follow-up, including responding to changes in patients needs
- Supporting patients self-management goals
- Linking to community resources
- Working to align resources with patient and population needs
Care coordination is important because it has the potential to improve the effectiveness, safety, and efficiency of the healthcare system. Well-designed, targeted care coordination that is delivered to the right people can improve outcomes for everyone: patients, providers, and payers.
While there is no consensus definition of care coordination, it involves the deliberate organization of patient care activities between two or more participants involved in a patients 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.
