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Module 5: Coordinated Care Delivery (COORD)

Thumbnail of downloadable Module 5 PPT Presentation.

The facilitation of timely, appropriate delivery of healthcare services by organizing PLWMCC’s care activities and sharing information among all members of the interprofessional care team involved in their care 1,2.
Making the Case for Coordinated Care Delivery for Persons Living With Multiple Chronic Conditions (PLWMCC)

Healthcare for PLWMCC often requires visits to multiple primary and specialty providers, and community-based programs. As a result, PLWMCC may receive numerous and/or redundant prescriptions, conflicting advice, and other duplicative services..  Care coordination improves communication among practitioners and has been shown to improve continuity of care for PLWMCC3,6.

The goal of care coordination is to ensure that all involved providers, PLWMCC and their families and caregivers have the information and resources needed to optimize care7. Achieving coordination of care depends on the timely communication of needs and preferences of PLWMCC to healthcare workers and others who provide safe, appropriate, and effective care to PLWMCC 8,9,3,.  Coordination of care is particularly important for PLWMCC  with literacy needs, low socio-economic status, poor living conditions, and language or cultural barriers because of the increased complexity of their medical and psychosocial care needs3.

Care coordination may improve the effectiveness, safety, and efficiency of the healthcare system and capacity to respond to the needs of multiple stakeholders 8,10 . For example, care should be focused on PLWMCC's individual goals and priorities even though other stakeholders such as practitioners and payers may seek to increase efficiency, improve high value care delivery, minimize unnecessary utilization, and reduce cost 3,11-14.  Acknowledging these different goals is a necessary step to developing care plans that provide  continuity of care resulting in outcomes such as reducing the frequency of emergency department visits and hospitalization, while also offering better preventive care, 15-18control of chronic diseases19, and higher patient satisfaction 16,20

Care coordination requires an interprofessional approach that focuses on the goals of PLWMCC. This is done by thoroughly assessing the needs and preferences of PLWMCC, developing a comprehensive care plan, and managing and monitoring healthcare and long term services and supports.21.  Linkages to community-based resources also are important elements of care coordination. 

In summary, basic components of successful care coordination may include: 

  • Understanding the life circumstances and preferences of PLWMCC and their families;
  • Relationship-based care: a trusting relationship between the interprofessional team,  community-based providers, and PLWMCC;
  • Establishing PLWMCC’s self-identified goals that are known to the entire clinical and community care team and are continuously reassessed;
  • Optimizing information transfer during transitions between care settings;
  • Utilizing communication techniques and tools such as electronic health records, registries, conference calls, patient portals, interprofessional team meetings, text messages, face time applications, and other social media;
  • Ensuring clear communication among the interprofessional care team members; and
  • Facilitating coordination between clinical and community settings that maximizes access of  PLWMCC to appropriate resources 3,8,21,22;

Learning Objectives by Competency

Competencies and associated learning objectives are presented below for use by educators.   The competencies apply to a wide variety of health professions students, faculty, and practitioners including physicians, nurses, psychologists, psychiatrists, dentists, pharmacists, social workers, allied health professionals, care coordinators, as well as interprofessional teams.   These competencies apply across the educational continuum, and can be discipline specific or interprofessional.  Examples of learning objectives are provided below.  Educators may tailor objectives for a specific healthcare discipline and for a specific phase of education.

COORD 1. Coordinate the management of care, including pharmacological and behavioral interventions, and community resources for PLWMCC across settings and providers.

Learning Objectives

  1. Ensure that all members of the interprofessional care team understand their roles, expectations, and responsibilities; and are committed to working together in the best interests of PLWMCC and their families and caregivers.
  2. Ensure that the interprofessional care team is knowledgeable about all medications (prescription and over-the-counter medications) being taken by PLWMCC.

COORD 2. Ensure communication and patient safety across transitions of care.

Learning Objectives

  1. Provide clear communication processes within and across settings of care.
  2. Ensure that communication among the interprofessional team members encompasses management of care transitions and medications, education of PLWMCC, and psychosocial issues 35.

COORD 3. Integrate the acute needs into the plan of care for PLWMCC 27.

Learning Objectives

  1. Document how acute changes in health affect the care plan.
  2. Adjust the care plan to address changes in care caused by acute illnesses.

COORD 4. Include preventive care and health promotion in the plan of care for PLWMCC.

Learning Objectives

  1. Implement evidence-based recommendations on clinical preventive services, such as vaccinations.
  2. Maintain a list of local community-based resources such as exercise and nutrition classes, chronic disease self-management education classes, smoking cessation resources, lay led empowerment workshops for preventive care and health promotion for all staff to refer to.

COORD 5. Promote mental health services as essential components of the plan of care for PLWMCC.

Learning Objectives

  1. Include mental health professionals on the care team.
  2. Integrate guidance from mental health professionals into the care plan.
  3. Refer to community-based mental health and social services as needed.

COORD 6. Facilitate effective healthcare delivery, with the consent of PLWMCC, by communicating information to all team members about the health of PLWMCC.

Learning Objectives

  1. Update all team members regarding PLWMCC care plans during interprofessional team meetings.
  2. Use electronic health records (EHR) and other means to communicate information within and across care settings.

Selected Curricular Resources

The following is a list of curricular resources that address, at least in part, Coordinated Care Delivery. Additional resources can be found in the MCC Education and Training Repository with live links.


1. McDonald, K. M., Sundaram, V., Bravata, D. M., Lewis, R., Lin, N., Kraft, S. A., McKinnon, M., Paguntalan, H., & Owens, D. K. (2007). Closing the quality gap: a critical analysis of quality improvement strategies (Vol. 7: Care Coordination).

2. McDonald, K. M. (2013). Considering context in quality improvement interventions and implementation: concepts, frameworks, and application. Acad Pediatr, 13(6 Suppl), S45-53.

3. Bayliss, E. A., Balasubramianian, B. A., Gill, J. M., & Stange, K. C. (2014). Perspectives in primary care: implementing patient-centered care coordination for individuals with multiple chronic medical conditions. Ann Fam Med, 12(6), 500-503.

4. Pham, H. H., Schrag, D., O'Malley, A. S., Wu, B., & Bach, P. B. (2007). Care patterns in Medicare and their implications for pay for performance. N Engl J Med, 356(11), 1130-1139.

5. Centers for Medicare and Medicaid Services. Chronic Conditions Among Medicare Beneficiaries. Chartbook: 2012. (2012).

6. Bodenheimer, T. (2008). Coordinating care--a perilous journey through the health care system. N Engl J Med, 358(10), 1064-1071.

7. Institute of Medicine (US). Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academy Press.

8. Agency for Healthcare Research and Quality-Care Coordination. Retrieved from http://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/.

9. McDonald, K. M., Schultz, E., Albin, L., Pineda, N., Lonhart, J., Sundaram, V., & Malcolm, E. (2010). Care coordination atlas version 3.  Rockville, MD

10. Corrigan, J. M., & Adams, K. (Eds.). (2003). Priority Areas for National Action:: Transforming Health Care Quality.: National Academies Press.

11. Bodenheimer, T., & Berry-Millett, R. (2009). Follow the money--controlling expenditures by improving care for patients needing costly services. N Engl J Med, 361(16), 1521-1523.

12. Song, Z., Sequist, T. D., & Barnett, M. L. (2014). Patient referrals: a linchpin for increasing the value of care. JAMA, 312(6), 597-598.

13. Bayliss, E. A., Edwards, A. E., Steiner, J. F., & Main, D. S. (2008). Processes of care desired by elderly patients with multimorbidities. Fam Pract, 25(4), 287-293.

14. Stremikis, K., Schoen, C., & Fryer, A. K. (2011). A call for change: the 2011 Commonwealth Fund Survey of Public Views of the U.S. Health System. Issue Brief (Commonw Fund), 6, 1-23.

15. Ionescu-Ittu, R., McCusker, J., Ciampi, A., Vadeboncoeur, A. M., Roberge, D., Larouche, D., Verdon, J., & Pineault, R. (2007). Continuity of primary care and emergency department utilization among elderly people. CMAJ, 177(11), 1362-1368.

16. Chan, C. L., You, H. J., Huang, H. T., & Ting, H. W. (2012). Using an integrated COC index and multilevel measurements to verify the care outcome of patients with multiple chronic conditions. BMC Health Serv Res, 12, 405.

17. Lin, W., Huang, I. C., Wang, S. L., Yang, M. C., & Yaung, C. L. (2010). Continuity of diabetes care is associated with avoidable hospitalizations: evidence from Taiwan's National Health Insurance scheme. Int J Qual Health Care, 22(1), 3-8.

18. Cheng, S. H., Chen, C. C., & Hou, Y. F. (2010). A longitudinal examination of continuity of care and avoidable hospitalization: evidence from a universal coverage health care system. Arch Intern Med, 170(18), 1671-1677.

19. Hong, J. S., Kang, H. C., & Kim, J. (2010). Continuity of care for elderly patients with diabetes mellitus, hypertension, asthma, and chronic obstructive pulmonary disease in Korea. J Korean Med Sci, 25(9), 1259-1271.

20. Adler, R., Vasiliadis, A., & Bickell, N. (2010). The relationship between continuity and patient satisfaction: a systematic review. Fam Pract, 27(2), 171-178.

21. Interprofessional Care Coordination: Looking To The Future. (2013) The New York Academy of Medicine (Vol. Issue Brief 1).

22. Boyd, C. M., & Lucas, G. M. (2014). Patient-centered care for people living with multimorbidity. Curr Opin HIV AIDS, 9(4), 419-427.

23. Singer, S. J., Burgers, J., Friedberg, M., Rosenthal, M. B., Leape, L., & Schneider, E. (2011). Defining and measuring integrated patient care: promoting the next frontier in health care delivery. Med Care Res Rev, 68(1), 112-127.

24. Cabana, M. D., & Jee, S. H. (2004). Does continuity of care improve patient outcomes? J Fam Pract, 53(12), 974-980.

25. van Walraven, C., Oake, N., Jennings, A., & Forster, A. J. (2010). The association between continuity of care and outcomes: a systematic and critical review. J Eval Clin Pract, 16(5), 947-956.

26. Patient-centered care for older adults with multiple chronic conditions: a stepwise approach from the American Geriatrics Society: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. (2012). J Am Geriatr Soc, 60(10), 1957-1968.

27. Workforce Competencies of Patient-Centered Health Care Delivery Through Health IT: A Framework for Practice Transformation. Retrieved from http://www.healthit.gov/sites/default/files/hie_role-based_competencies.pdf.

28. The New York Academy of Medicine Center for Evaluation. Perspectives on Care Coordination: Voices of Older New Yorkers. (2010). Retrieved from http://www.nyam.org/social-work-leadership-institute/docs/publications/Older-Adult-s-Perspectives-of-Care-Coordination.pdf.exit disclaimer icon

29. Academy Health. Research Insights: What works in care coordination? Activities to reduce spending in Medicare Fee-for-service.

30. Naylor, M. D., Bowles, K. H., McCauley, K. M., Maccoy, M. C., Maislin, G., Pauly, M. V., & Krakauer, R. (2013). High-value transitional care: translation of research into practice. J Eval Clin Pract, 19(5), 727-733.

31. Grand-Aides Program. Retrieved from http://www.grand-aides.com/ exit disclaimer icon

32. Reducing Care Fragmentation: A Toolkit for Coordinating Care. Retrieved from http://www.improvingchroniccare.org/downloads/reducing_care_fragmentation.pdf.exit disclaimer icon

33. Mann, K., Sargeant, J., & Hill, T. (2009). Knowledge translation in interprofessional education: what difference does interprofessional education make to practice? Learning in Health and Social Care, 8(3), 154-164.

34. Soubhi, H., Bayliss, E. A., Fortin, M., Hudon, C., van den Akker, M., Thivierge, R., Posel, N., & Fleiszer, D. (2010). Learning and caring in communities of practice: using relationships and collective learning to improve primary care for patients with multimorbidity. Ann Fam Med, 8(2), 170-177.

35. Brown, R., Reikes, D., and Peterson, G. . (2009). Features of Successful Care Coordination Programs: Webinar on Care Management of Patients with Complex Health Care Needs. Robert Wood Johnson Foundation: Mathematica Policy Research.

36. Indian Health Service. Patient-Provider Communication Toolkit. Healthcare Communications. Retrieved from http://www.ihs.gov/healthcommunications/index.cfm?module=dsp_hc_toolkit.

37. Center for Substance Abuse Treatment. Enhancing Motivation for Change in Substance Abuse Treatment. (Treatment Improvement Protocol (TIP) Series, No. 35.) Chapter 3—Motivational Interviewing as a Counseling Style. . (1999).  Rockville, (MD):  Retrieved from Available from: http://www.ncbi.nlm.nih.gov/books/NBK64964/.

38. Agency for Healthcare Research and Quality Clinical-Community Linkages. Retrieved from http://www.ahrq.gov/professionals/prevention-chronic-care/improve/community/.

39. Woolf, S. H., Dekker, M. M., Byrne, F. R., & Miller, W. D. (2011). Citizen-centered health promotion: building collaborations to facilitate healthy living. Am J Prev Med, 40(1 Suppl 1), S38-47.

40. Ferrante, J. M., Cohen, D. J., & Crosson, J. C. (2010). Translating the patient navigator approach to meet the needs of primary care. J Am Board Fam Med, 23(6), 736-744.

41. Fried, T. R., Tinetti, M. E., & Iannone, L. (2011). Primary care clinicians' experiences with treatment decision making for older persons with multiple conditions. Arch Intern Med, 171(1), 75-80.

42. Institute of Medicine. Informing the future: critical issues in health. Pharmaceuticals: the good and the bad. (2007). Washington. Retrieved from http://www.nap.edu/catalog.php?record_id=12014. exit disclaimer icon

43. U.S. Department of Health and Human Services. Healthfinder.gov. Retrieved from www.healthfinder.gov.

44. Hernandez, L., Anderson, K., & Chao, S. (2009). Toward Health Equity and Patient-Centeredness:: Integrating Health Literacy, Disparities Reduction, and Quality Improvement: Workshop Summary. National Academies Press.

45. Galanti, G. A. (2000). An introduction to cultural differences. West J Med, 172(5), 335-336.

46. Broome, B. (2006). Culture 101. Urol Nurs, 26(6), 486-489.

47. Chang, M., & Kelly, A. E. (2007). Patient education: addressing cultural diversity and health literacy issues. Urol Nurs, 27(5), 411-417.

48. Sampalli, T., Fox, R. A., Dickson, R., & Fox, J. (2012). Proposed model of integrated care to improve health outcomes for individuals with multimorbidities. Patient Prefer Adherence, 6, 757-764.

Content created by Assistant Secretary for Health (ASH)
Content last reviewed on July 1, 2015