Care Coordination Solutions for Doctors


Care coordination is the process of deliberately organizing patient care activities and sharing information among all the participants concerned with a patient’s care (i.e Doctors, nurses, pharmacists etc) to achieve safer and more effective care.This means that the patient’s needs and preferences are known ahead of time and communicated at the right time to the right people and that this information is used to provide safe, appropriate, and effective care to the patient.

Care Coordination Solutions for Doctors come in various forms. The most recent and advanced Care Coordination solution for doctors is a mobile, tablet-based application, used at the point of care by care coordinators and team members to organize patient interventions including shared decision making for patient goals & activities, patient and team communications, as well as alerts and notifications for new admissions or decreasing patient engagement activity. It’s a technology provided by Health Catalyst.

The main goal of care coordination is to meet the patients’ needs and preferences in the delivery of high-quality, high-value health care. This means that the patient’s needs and preferences are known and communicated at the right time to the right people and that this information is used to guide the delivery of safe, appropriate, and effective care.

There are two ways of achieving coordinated care solutions for doctors. The first is using broad approaches that are commonly used to improve healthcare delivery and the other is using specific care coordination activities.

Examples below

Broad Approach Care Coordination Specific Care Coordination
Care management.
Medication management.
Health information technology.
Patient-centered medical home. 
Establishing accountability and agreeing on responsibility.
Communicating/sharing knowledge.
Helping with transitions of care.
Assessing patient needs and goals.
Creating a proactive care plan.
Monitoring and followup, including responding to changes in patients’ needs.
Supporting patients’ self-management goals.
Linking to community resources.
Working to align resources with patient and population needs. 

Why Is Care Coordination Important?

Care coordination is identified by the Institute of Medicine Link to Exit Disclaimer as a key strategy that has the potential to improve the effectiveness, safety, and efficiency of the American health care system. When care coordination is well designed and targeted properly, it can improve outcomes for not only patients but also for providers and payers as well. Though there is clearly a need for care coordination solutions for doctors, there are obstacles within the American health care system that must be overcome to provide this type of care.

These obstacles need to be removed and the healthcare system needs to be redesigned in order to better coordinate the care of patients. And if you think calling for a redesign is too drastic, consider the following reasons why it’s very important:

  • Current health care systems are often disjointed, and processes vary among and between primary care sites and specialty sites.
  • Patients are often unclear about why they are being referred from primary care to a specialist, how to make appointments, and what to do after seeing a specialist.
  • Specialists do not consistently receive clear reasons for the referral or adequate information on tests that have already been done. Primary care physicians do not often receive information about what happened in a referral visit.
  • Referral staff deal with many different processes and lost information, which means that care is less efficient.   

So how can this call for coordinated care reform in the healthcare system be put into action? Well, applying changes in the general approach and everyday routines of a medical practice can be overwhelming, even when it is obvious that the changes will improve patient care and provider efficiency. Fortunately, there are resources available for those who are interested in learning how to take a coordinated care approach to primary care practice.

The Care Coordination Quality Measure for Primary Care (CCQM-PC) builds on previous AHRQ work to develop a conceptual framework for care coordination. The CCQM-PC is intended to fill a gap in the care coordination measurement field by assessing the care coordination experiences of adults in primary care settings. It was developed, cognitively tested, and piloted with patients from a diverse set of 13 primary care practices to comprehensively assess patient perceptions of the quality of their care coordination experiences.