Care Coordination Today: What, Why, Who, Where, and How?


Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD

Series Editor: Barney S. Spivack, MD, FACP, AGSF, CMD

Historically, “good” clinical geriatric care was pictured to consist of solo physician practitioners tending to the needs of their older patients across all care settings, from home, to hospital, to long-term care. This picture has evolved, and today’s “best” practice includes an interdisciplinary care team (IDT). This is in part because of the complexities of providing geriatric care, particularly in today’s healthcare environment, which requires balancing an increasing number of clinical, logistical, financial, and regulatory variables. There has been widespread interest in developing solutions that overcome these challenges to improve the effectiveness and efficiency of the healthcare system. This task is especially vital given the complexity and resource constraints facing Medicare as baby boomers age and the federal budget constricts. 

One proposed solution to the problem is care coordination, a strategy the Institute of Medicine has deemed to be instrumental for optimizing care, as it has the potential to reduce cost and improve outcomes for all populations in all healthcare settings. However, the most impressive outcomes with care coordination have been observed for high-risk populations whose complex health issues involve costly treatments and often result in repeated hospitalizations. Because of the importance of care coordination, it is a required element of the Patient-Centered Medical Home (PCMH) model. In the PCMH model, coordination is meant to ensure that care is organized across all elements of the broader healthcare system, including specialty care, hospitals, home healthcare, and community services and supports. This article examines many questions regarding care coordination and reviews issues surrounding its implementation. 

What Is Care Coordination? 

Care coordination is sometimes used synonymously with case management or care management, but each of these terms has a slightly different focus. According to the National Quality Forum,care coordination is “a function that helps ensure that the patient’s needs and preferences for health services and information sharing across people, functions, and sites are met over time,”1whereas the Taber’s Cyclopedic Medical Dictionary defines case management as an “individualized approach to coordinating patient care services for individuals with complex healthcare needs or chronic medical problems.”2 Blue Cross describes case management as “coordination of services to help meet a patient’s healthcare needs, usually when the patient has a condition requiring multiple services from multiple providers,” and it defines care management as “healthcare services and programs designed to help individuals with certain long-term conditions better manage their overall care and treatment.”3 As these definitions show, although care coordination, case management, and care management have similar functions and objectives, their approaches are different. Care coordination is meant to be more inclusive as a patient- and family-centered approach for care delivery, whereas case management and care management have a more structured, healthcare-environment–focused approach for care delivery. Regardless of the approach, coordination of care is being viewed as a foundation in accountable care organizations (ACOs) and in other emerging models of care as a means of producing higher quality care at a lower cost for patients and the system as a whole.

Why Is Care Coordination Needed?  

Care coordination is needed for numerous reasons. First and foremost, lack of coordination can be unsafe, even fatal. When abnormal test results are not communicated correctly between multiple providers or between providers and patients, when prescriptions are issued by multiple physicians and there is unawareness of the medications the patient is already taking, and when primary care physicians (PCPs) do not receive hospital discharge plans for their patients, the risk of poor patient outcomes is high. These are just a few of the scenarios that may arise from uncoordinated care. 

Second, as noted by the American College of Physicians, uncoordinated care is more costly for patients and the healthcare system, as it increases duplicate services, increases the risk of preventable hospital admissions and readmissions, and contributes to overuse of more intensive procedures.4 On average, patients who receive uncoordinated care are estimated to pay 75% more for their healthcare services than matched patients with coordinated care.5 Owens6 suggested that enhanced care coordination could reduce 35% of costs. Because of the recognized impact of care coordination, the Patient Protection and Affordable Care Act invokes care coordination throughout its provisions to improve the quality of care and control costs to transform the healthcare-delivery system. Care coordination is also a key feature of evolving ACOs, which seek to integrate effective care coordination with accountability, incentives, and quality measurement.

There is growing evidence that care-coordination programs work, are beneficial in various organizational settings, and can be supported through different financial means. Mathematica Policy Research7 found several studies of at least moderate internal validity that showed improvements in quality of life for persons under care-coordination programs. Claiborne described a care-coordination program for stroke survivors that was supported by mixed funding sources.8 Compared with persons receiving regular care (n=12), the coordinated-care group (n=16) showed significantly improved quality of life, decreased depressive symptoms, and increased adherence to self-care practices. In this program, social workers coordinated a wide range of medical and social services using a standardized, problem-solving care-coordination model. 

In 2010, Marek and colleagues9 reported improved activities of daily living and a decrease in pain and other symptoms for 55 nursing-home–eligible elders participating in the Aging in Place program, which was financed by both Medicare and Medicaid. In the program, care coordination was provided by specially trained nurses who operated in a fully integrated model, managing a broad range of medical and long-term care services and supports. Comprehensive needs assessment and periodic home visits were also elements of this care-coordination intervention.

Who Oversees Coordinated Care? 

In today’s healthcare environment, the IDT is tasked with navigating healthcare challenges and coordinating care through all settings, with the dual objective of improving outcomes for patients and sparing already taxed healthcare system resources, such as by reducing the frequency of hospital admissions and services. To realize the IDT’s role in care coordination, it is important to understand who comprises the IDT and each member’s role in this endeavor. 

Today’s IDT can consist of nursing staff, pharmacists, social workers, physician extenders (ie, nurse practitioners and physician assistants), and therapists. With so many different persons potentially involved in any patient’s care, it is easy to see how challenging care coordination can be, but it is also apparent that these teams have the potential to deliver tremendous results because of their combined expertise. For care coordination to be optimized, it is essential for every member of the team to know his or her role and the role of the other members and to work together. 

Although all IDT members play a role in care coordination, nurses take center stage in this arena, often becoming the care coordinators. This is not surprising given care coordination is considered a professional competency of all registered nurses. As a result, these healthcare professionals are generally the ones tasked with coordinating communication and healthcare efforts between the other healthcare members and with patients to improve patient care across healthcare settings and populations. In the American Nurses Association position statement, The Nurse’s Essential Role in Care Coordination,5 registered nurses are noted to be integral to achieving care-coordination excellence. This stance is also taken by a National Coalition on Care Coordination white paper, which describes the roles and benefits of nursing in the care-coordination process and provides evidence of the centrality of registered nurses to healthcare that is patient-centered, high-quality, and cost-effective.10

Payers also play a key role in the care-coordination process, as they provide care-coordination fees to the ACO to support the work of the IDT teams. Both government (Medicare/Medicaid ACO models) and private payers (managed care organizations) promote and contract with ACOs and provide them with care-coordination funds. These funds can be paid concurrently and are an important part of cash flow for ACOs.

Recently, the Centers for Medicare & Medicaid Services issued a policy to pay physicians to coordinate patients’ care in the 30 days following a hospital or skilled nursing facility stay.11 This recognizes the work of community physicians in treating patients following a transition of care and strives to ensure better continuity of care and reduce readmissions. Physicians can bill one of two codes, depending on the complexity of the service provided: the higher-level billing code requires a face-to-face visit with the patient within 1 week of discharge, and this code is expected to provide a reimbursement of $230; the lower-level code, which requires a face-to-face visit within 2 weeks, is expected to provide a reimbursement of $160. These additional funds could be used to support the addition of care-coordination staff.

Where Does Care Coordination Occur? 

Care coordination can occur in a variety of settings, as IDT members can exist as independent practitioners; employees of healthcare plans, which is especially relevant in special needs plans; or as part of a provider-based organization. It is increasingly common for IDT members to be employed by ACOs or similar providers rather than the traditional arrangement through health plans and healthcare systems. But it sometimes remains unclear which entity is best suited for employing the care coordinator to optimize his or her level of integration into the practice. 

Today, because the PCP’s office still represents the base for most outpatient care, it can provide an ideal site for care coordination. In one pilot program,a national insurer placed nurse case managers in PCPs to work alongside providers in their offices to help manage patients’ conditions.12 This pilot found that having case managers embedded at physicians’ offices increased their ability to effectively manage patient care, compared with typical telephone-based approaches. It is thought that this was the result of their enhanced ability to collaborate with physicians and other staff via regular, face-to-face contacts and establish trust over time. Case managers also benefited from working in these data-rich environments, as this facilitated their ability to track performance on agreed-upon quality measures. The reported benefits included improved care processes, some improvements in care outcomes, and fewer hospitalizations.

Outside of the PCP office, another site for care and care coordination is the home. An in-home health consultation program, which was provided by advanced practice nurses and guided by the principles of health promotion, empowerment, partnership, and family-centeredness, has been reported to be effective in reducing adverse health outcomes, such as falls, acute events, and hospitalizations.13 While the care coordination based in the PCP office and home can stand alone, a preferred approach may be combining home care with office-based care. This has occurred in the Guided Care® program.14 Guided Care is proposed as a solution to the growing challenge of caring for older adults with chronic conditions and complex health needs. Guided Care nurses partner with physicians and other healthcare providers in primary care to provide coordinated, patient-centered, cost-effective care to persons with multiple chronic conditions. The nurse conducts in-home assessments, facilitates care planning, promotes patient self-management, monitors conditions, coordinates the efforts of all care professionals, smoothens transitions between sites of care, educates and supports family caregivers, and facilitates access to community resources.

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