Coordinated Care Best Practices = Successful Outcomes

Posted by Continuum on Apr 27, 2015 2:40:52 PM


The Need for Coordinated Care

The number of Americans with at least one chronic health condition is rising. A Commonweath Fund International Survey found that 23% of patients with a chronic illness saw four or more doctors over the last year and 46% reported taking four or more prescriptions on a regular basis.1 These patients have higher than average healthcare utilization rates, making the management of their care particularly vital, yet complicated. Consequently, a targeted care coordination program is an essential component of any larger Population Health Management initiative.

The successful management of patients with chronic conditions requires care that is well-coordinated between providers, patients, and the care team. The Institute of Medicine has remarked that care coordination “has the potential to improve effectiveness, safety and efficiency of the American health care system”2 and can result in higher survival rates, fewer emergency department visits, and lower medication costs.3 Furthermore, a Health Affairs policy brief found that the lack of coordinated care is costly and created $25 to $45 billion in wasteful spending in 2011 through avoidable complications and unnecessary hospital admissions.4


What is Care Coordination? 

The Agency for Healthcare Research and Quality defines care coordination as “deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care.” This includes determining the patient’s needs and preferences and communicating them “at the right time to the right people.5

Although the terms are often used interchangeably, care coordination is distinct from care navigation. Navigation is narrower in scope and is usually confined to a brief checklist of tasks such as verifying that an ER patient has scheduled a follow-up visit with his physician or confirming that the patient has obtained prescribed medications.

Continuum has developed an extensive white paper outlining care coordination activities, a proven coordinated care model and best practices, available for download now or at the end of this blog.

The Benefits Justify the Investment

Proper care coordination assists providers in meeting the “Triple Aim” – better patient experience, improved health for the community, and lower overall costs.8 For example, care coordination enables providers to:

  • Work at the top of their credentials. Physicians have more quality time for patients, since patient care coordinators (PCCs) can directly handle or facilitate with the physician’s care team a wide range of patient care tasks.
  • Improve utilization management. Care coordination allows physicians and other care team members to focus on proactive care, rather than react to expensive acute care episodes.
  • Engage patients in their own care. As extensions of the physician and his/her care team, PCCs can stay closely connected to patients. Regular communications help engage patients and focus their attention on preventative actions.
  • Enter into value-based contracts with greater confidence. Most value-based models require providers to demonstrate ongoing quality improvement, patient satisfaction and lower overall cost of care – rigorous but achievable goals with a strong care coordination structure.

Practice-Based vs. Centralized Care Coordination

When the concept of care coordination first emerged, practices typically delegated the care coordination function to their internal staff. However, this approach proved too costly for many
practices, particularly those that still relied on traditional fee-for-service payment models that didn’t offer reimbursement for care management services. In addition, many practices had difficulty finding individuals with the required education and credentials to handle the multiple tasks of care coordination.

Continuum discovered that practices could achieve better results and save money if the care coordination function was centralized and services/costs were shared among multiple practices. Continuum’s Centralized Care Coordination team includes registered nurses acting as patient care coordinators (PCCs), a social worker, and experienced support staff. The model also includes specific metrics regarding PCC/Patient ratios, detailed in the whitepaper.

A Dozen Great Ideas

Continuum has developed 12 best practices in care coordination that drive overall results. Read more by downloading "Coordinated Care Key to Successful Outcomes: Best practices in care coordination improve health, lower costs and increase patient satisfaction."

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To discuss how Continuum can assist in better coordinating care for your patients, please contact: Devon Swanson, (856) 782-3300 ext. 2419 or


[1] C. Schoen, R. Osborn, D. Squires, M. M. Doty, R. Pierson, and S. Applebaum, New 2011 Survey of Patients with Complex Care Needs in 11 Countries Finds That Care Is Often Poorly Coordinated, Health Affairs Web First, Nov. 9, 2011.

[2] “Care Coordination;” Agency for Healthcare Research and Quality, downloaded February 1, 2015,

[3] The benefits cited by the American Nurses Association (AHA) apply to care coordination provided by nurses. “The Value of Nursing Care Coordination;” AHA, June 2012, p. 2.

[4] “Improving Care Transitions;” Health Affairs, Sept. 13, 2012,

[5] “Care Coordination;” Agency for Healthcare Research and Quality

Topics: Coordinated Care, population health management, care coordinators


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