What is patient care coordination?

A healthcare roadmap can be complicated. A person might receive care simultaneously from a primary care physician (PCP), a physical therapist, and a specialist helping them manage a chronic condition.

Because healthcare happens in various settings and is given by various organizations and people, it’s easy for patient information to become siloed. When this occurs, information is not shared between healthcare providers. Siloed patient care can lead to problems such as drug interactions, conflicting information, and duplicate testing. It can also cause the patient to pay more for unnecessary testing and medication, adding to their condition’s financial impact.

Patients can get the highest quality care possible when it’s coordinated across all healthcare providers. They are more likely to have their needs met and experience better healthcare outcomes. This can also lead to better patient satisfaction and increased compliance with the care plan, as it includes input from all team members and encourages the patient to have more trust in the decisions being made.

Ultimately, care coordination takes all the puzzle pieces of healthcare and fits them together. 

Learn more about care coordination and why it’s essential to delivering efficient and effective patient care.

Patient care coordination is the deliberate organization of healthcare services an individual receives. Healthcare providers work together to unify their care efforts, addressing the medical, psychological, and social aspects.

By fostering better communication- and information-sharing among healthcare providers, patient care coordination can improve safety, results, and overall patient care.

Who coordinates a patient’s care?

A care coordinator or care manager typically oversees care coordination. The care coordinator might be a nurse, social worker, or healthcare professional with experience in managing complex medical cases.

The care coordinator organizes a patient care plan and acts as a central point of contact for the patient and their healthcare providers. They work with other healthcare providers to address all aspects of the patient’s care, including religious, social, and educational aspects. They can also advocate for the patient, helping them get the necessary services and ensuring the medical team follows their wishes.

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Patient care coordination is always helpful, even within routine medical care. However, it’s even more critical when patients face complex medical conditions or trauma that require many avenues of treatment. Here are some examples:

• Chronic diseases like diabetes, heart disease, or cancer, where multiple specialists may be working with one patient

• Traumatic injuries where there is a physical injury as well as psychosocial components that may prevent healing if not addressed

• Elderly patients facing complex medical needs and relying on multiple caregivers and support services

• Patients with mental health conditions who need to coordinate between medical and mental healthcare providers

• Patients managing multiple medical conditions simultaneously

Care coordination can also be necessary when a patient has religious beliefs to consider.

Patient care coordination can involve many people, depending on the patient’s condition, health concerns, and specific needs. Along with the patient themselves, below are some of the other people who may be involved in coordinated care:

• Primary care physicians—often the first point of contact for patients in the healthcare system

• Specialists who may be treating the patient for complex health issues

• Nurses who administer treatments in a hospital, clinic, or home setting and who educate the patient about their care

• Pharmacists who ensure the patient gets the proper medication, explain potential drug interactions, and help manage medications

• Therapists who may be involved in the rehabilitation process after surgery or illness

• Social workers who assess the social and emotional needs of the patient and help connect them to community resources

• Family and caregivers supporting the patient at home or in a facility

• Clergy can be involved to honor a patient’s religious beliefs

Patient care coordination depends on effective communication and collaboration. Many providers will hold “care conferences,” bringing the patient’s healthcare team together to discuss treatment plans. At the care conference, the medical professionals can coordinate efforts and use shared decision-making to create a centralized care plan for the patient. That plan then becomes a road map for the team with goals for recovery.

Electronic health records (EHRs) are vital to patient care coordination. EHRs are a centralized database of patient information accessible to all medical professionals. By digitizing and sharing the patient’s health information, medical providers throughout the healthcare roadmap can access up-to-date patient information to make better decisions about future treatments.

Care coordination should also involve the desired or correct form of communication, and this should comply with the Health Insurance Portability and Accountability Act (HIPAA). Communication may occur via email, virtual conferences, faxes, or phone calls. Care coordinators can ensure that everyone has the correct contact information for all team members involved.

Providers can also play a role in care coordination by educating patients. Patients and their caregivers should have information about their condition and know all their treatment options. This can empower them to participate actively in their care journey and become an advocate for their healthcare.

The services included in care coordination will depend on the patient’s needs, medical condition, and personal circumstances.

Multiple specialists may be involved in a patient’s coordinated care plan if they have complex medical conditions, such as cancer or chronic illness. Taking the patient’s financial resources, support system, and preferences for care into account is also essential when determining which services to include. 

The goal of care coordination is to

• Include services that ensure the patient receives the right care at the right time

• Reduce re-hospitalizations and the length of hospital stays

• Avoid duplicating services, tests, and treatments

• Improve communication between all healthcare providers

• Support patients, their families, and their caregivers in self-management and advocating for the patient

Mr Moss is a 75-year-old retired man with multiple chronic conditions, including diabetes, hypertension, and arthritis. Mr Moss’ care coordination starts with a wellness check conducted by his PCP. The PCP decides Mr Moss could benefit from coordinated care to help manage his conditions more effectively. He refers Mr Moss’ case to a care coordinator.

The care coordinator, a skilled nurse with experience managing complex healthcare cases, works with Mr Moss and his healthcare team. The nurse develops a personalized care plan that incorporates each specialist’s expertise, addressing medication management, lifestyle modifications, and pain management strategies.

Additionally, a pharmacist ensures there are no adverse reactions in Mr Moss’ medication list. And because Mr Moss can no longer drive himself, a social worker identifies community resources to assist with his transportation needs.

The care coordinator schedules regular care conferences, where all team members discuss Mr Moss’ progress, make necessary adjustments to his care, and provide patient education. They use telehealth services so Mr Moss can attend virtual consultations, helping reduce his transportation needs and ease the burden of trying to get out of the house with his mobility issues. The team also coordinates home healthcare services and visiting physician groups to manage the transportation issues.

The nurse will also ensure that the care plan meets Mr Moss’ medical wishes and that it is communicated to Mr Moss’ family if needed.

Mr Moss can reduce the cost of his care because his healthcare team is coordinated. The number of unnecessary tests and medications is reduced as he can work together with his medical team more effectively.

In the future, he may experience better outcomes in treatment and a better quality of life thanks to coordinated care.