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Care Coordination Built on 10 Shared Assumptions

By Christopher Cheney  
   November 29, 2018

Care coordination covers a multitude of activities and requires a coherent collaborative effort among policy makers, payers, community agencies, healthcare providers, and families.

Care coordination features an essential set of services, particularly for patients with conditions that are complex and long-term, a recent article in JAMA Pediatrics says.

To deliver effective care coordination, healthcare providers and community partners should have key shared assumptions such as comprehensive assessments of patient needs, a written care plan, and coordination between clinicians and community service professionals.

"Despite the centrality of care coordination to healthcare reform, practice redesign, and chronic care management, there remain multiple definitions, expectations, and approaches to its provision. This variability reflects the different purposes for which care coordination is intended, such as improved quality, reduced healthcare use and costs, more comprehensive care, meaningful response to social determinants of health, and planning care over the life course," the JAMA article's author wrote.

This week, the author told HealthLeaders that establishing shared assumptions about care coordination is crucial to extending the concept to include the personal and social circumstances of patients and their families.

"In the past, care coordination focused on coordinating among medical care providers and, sometimes, other healthcare providers. Today, the need to address the patient's social needs such as housing, nutrition, social support, and education to achieve good health outcomes is appreciated and some health plans and payers, including Medicare and Medicaid, are beginning to pay for such services as legitimate health expenses," said Edward Schor, MD, of the Lucile Packard Foundation for Children's Health in Palo Alto, California.

Schor's article highlights 10 pivotal shared assumptions for care coordination.

1. Teamwork emphasized

Care coordination should be family-centered and team-based with clearly established goals, frameworks, and obligations.

2. Assessment conducted

Services should be crafted and deployed based on a comprehensive assessment that gauges the health and psychosocial needs of the patient.

3. Plan promulgated

Care coordination services should be documented in a written care plan designed by the patient, family, and healthcare providers. "It is generally not possible to have coordination in the absence of a plan. Otherwise, service providers are merely reacting," Schor said.

4. Care plan monitored

The plan for care coordination services should be supervised on a regular basis and revised as needed.

5. Communication expanded

Electronic communication should supplement face-to-face communication between the patient, family, and healthcare providers to strengthen the working relationships between clinicians and others involved in the patient's care.

6. Information shared

The patient and the family should be given information and supports that can help them manage the patient's care.

7. Community professionals included

Healthcare providers should coordinate their efforts with community-based professionals who offer services and support to the patient and family.

8. Care coordinator assigned

Patients should have an assigned care coordinator who has regular contact with the family and primary clinician.

9. Information shared electronically

An electronic medical record should be used to share the patient's health information with family members and all healthcare providers.

10. Transitions of care managed

Any patient transitions between settings should be managed to ensure continuous access to care. "Care coordination for transition, whether between settings or from pediatrics to adult care, is hazardous, especially for patients with chronic or complex health conditions. I consider transition services to be a subcomponent of care coordination," Schor said.

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


Establishing a shared set of assumptions can help ensure effective care coordination between patients, families, clinicians, and community service providers.

Multiple definitions, expectations, and approaches to care coordination can be problematic.

Transitions of care should be managed robustly to avoid breakdowns in care coordination.

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