23 Jan, 2019
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23 Jan, 2019
Follow Coleman!

Care Coordination: Building a Foundation

Whether you are exploring the creation of a new care coordination program or expansion and refinement of a current program, there are many items to consider. Each organization and practice has a different care environment with unique challenges and patient population needs, and most programs share many needs and goals in care coordination program development and refinement. When care coordination programs are designed and implemented well, they can serve as an important facet in improving patient care and helping providers and organizations succeed in value-based payment (VBP) models. To begin building or refining your care coordination program, you must consider and evaluate all of the elements that contribute to successful care coordination activities across organizations and networks, and analyze your needs and areas for improved success.

Understand Your Financial Platform

The Centers for Medicare and Medicaid Services (CMS) have a variety of VBP models, and commercial payers are following suit by developing their own variations based on the CMS models. Before you begin designing your care coordination program, you should explore the reality (and potential) of your financial platform. Our Overview of Value Based Payment will help you to better understand and prepare for VBP changes, and will provide you with a foundation upon which to begin building your care coordination program.

The finances of a care coordination program can be complex and are often viewed as a barrier. Including individuals from your organization who understand your finances, VBP, and the future of health care finance will be imperative to creating a viable program and ensuring long term program sustainability. Organizations should explore reimbursement models and complete a cost-benefit analysis to ensure that they can afford to build and sustain the care coordination model that they select.

Determining which VBP programs or risk-based contracts are currently in place at your organization is an important step in planning your care coordination program. Understanding how you get paid within these contracts will help you determine what your organization can support financially and will help you develop programs, processes, systems, and relationships to address patient needs as they relate to specific contracts and programs. When investigating VBP programs, we suggest performing a cost-benefit analysis on multiple programs, as it is unlikely that a single model will be adopted in the future.

CMS considers chronic care management (CCM) the coordination of services for patients with complex health needs in the form of multiple chronic health conditions. In addition to VBP and risk-based contracts, CMS has created CCM as unique codes resulting in payments for the additional resources and time needed to manage patients with complex needs. Revenue generated by CCM care should be considered when evaluating the overall financial platform of your care coordination program. Appropriate use and billing for these services can provide significant support to your care coordination program.

Identify Your Patient Population

Before you can begin to design your care coordination program, you must understand the needs of your patient population, but first you must know who your patient population is. In the United States, we know that a relatively small proportion of patients make up the large majority of our health care expenditures. These patients have multiple comorbidities (medical and psychosocial) and are challenged by social determinants of health. They often lack the ability to navigate our complex health system, resulting in fragmented care and increased spending in the form of unneeded lab tests and imaging, frequent (and avoidable) visits to the emergency room, and longer than average hospital stays. Studies estimate that 20% of the population uses 80% of our healthcare dollars so it is important to identify your 20%. This population is the most logical and strategic place to start for organizations in the early stages of developing a care coordination program.

Health Information Technology (HIT) can help you create predictive algorithms to conduct risk stratification and effectively target a patient population for your care coordination program. There are a variety of risk stratification methods; each method targets specific populations (Medicare, elderly) and has different data and software requirements. Your budget, staff capacity, and CC goals will all be factors in deciding if any of these methods would be appropriate for your organization. To begin, we suggest that you use our Patient Identification Tool.

As your organization’s program grows, you may choose to expand and hone in on a population outside of the 80-20 estimates. Using HIT, you can utilize more advanced methods that are effective in identification of patients who are medium or moderate risk, with the ultimate goal of preventing them from migrating to moderate or high risk. A third strategy is to identify a subgroup of high complexity patients who have modifiable risk factors, and implement care plans and interventions to target that specific population.

Engaging Key Stakeholders

Fostering support from the appropriate people is a crucial component of every stage of a care coordination program, from development to maintenance. Engaging key stakeholders early and often will prove very beneficial, resulting in comprehensive program design and adoption, ongoing support of strategic initiatives, and assurance of long term sustainability. Who should you engage? Carefully consider the overarching benefit of each participant and identify what you anticipate the outcome will be given each person’s involvement. Create a system that will organize your potential stakeholders, their roles, and the benefits/outcomes of their participation.

There will be a variety of key stakeholders for each unique care environment/community, likely including the following:

  • Patients: the patient is a critical participant in any care coordination program and should not be excluded from this process. Consider having members of your patient advocacy group (if you have one) join your process. Including the patient perspective in your process will help you interpret their perception of the services you intend to offer, assess how your population will respond to your program, and allow you to find unique methods to reach and interact with your patient population.
  • Senior Leadership: these members are your ‘levers.’ We call them ‘levers’ because they are in a unique position to help provide you with the resources you need, including staffing. They will likely be heavily influential in the overall program design, resource allocation, and in setting goals for the program.
  • Physicians and Care Community: care providers will be key influencers in development, implementation and refinement of a care coordination program. They will provide essential governance to the care being delivered, facilitate relationships among the care community, align and evaluate outcomes of the program, and act as ‘champions,’ meaning they will be highly invested in the program and will get buy-in from other providers and members of the healthcare community.
  • Community Resources: these members will likely vary depending upon the target population and the resources that exist in the local community. They can include specialists, pharmacists, local public health departments, school staff, and more. Adding these members to your key stakeholder group will help drive community collaboration, align community resources to support patient needs, and create smooth transitions for patients.

Once you have identified your key stakeholders, clearly define why their participation in the program is beneficial to the program as well as the stakeholder. How or why does it benefit them to participate? This clarity it critical to a successful plan as you work to recruit them to participate in different stages of your care coordination program. Often times, the stakeholders you identify have a unique drive and benefit from involvement (altruism, investment); including those items in your invitation will strengthen the likelihood of participation.

Once you have all of the stakeholders identified and committed, develop a plan to keep them engaged and involved in the ongoing efforts and processes. This will help drive continual improvement and ensure sustainability of your care coordination program. One of the most simple but often underestimated strategies to keeping your key stakeholders engaged is to communicate often. What you choose to communicate will vary but should include some basics: success, major improvements/changes made, any upcoming redesign with supporting data, opportunities for additional program development, and the short or long-term vision of the program and initiatives.

Building A Network 

Once you have engaged key stakeholders, identified your patient population, and examined your financial environment, you can begin to create your care network. Creation of a care coordination program requires that the practice or organization take full responsibility for the full spectrum of care that patients receive, even if the care is not being delivered in their facility or a facility within their organization. Involving multiple care providers and service locations has historically been an opportunity for the breakdown of care, and has caused many patients to fall through the cracks. However, in this age of care coordination programs, creating a network made of multiple providers and service locations offers an opportunity for improved patient outcomes and cost control.

To successfully prevent care gaps and control costs within the patient referral and transition process, organizations must develop and maintain relationships with referring and consulting providers as well as community resources. This system-level approach will facilitate care across the broad spectrum of the healthcare system, and ensure that all providers involved in the patient care experience have a shared purpose and recognize the importance not only the referral, but the care network.

The first step in creating this network is to identify the specialists, groups, facilities and community partners who will be most active in supporting your defined patient population. Having defined your network, you can then begin relationship building. Engaging in conversations about preferences and expectations will begin the development of a shared vision for services and care delivery agreements. These are essential components of network development. The goal of these agreements is to reduce unnecessary referrals, expedite and streamline patient care, improve communication among providers (including the transfer of patient records), and optimize patient transitions.  See our Care Network Building Guide for more guidance.

Once you fully understand your financial platform and capacity, have identified your patient population, have engaged stakeholders and began building your network, you can begin bringing your care coordination vision to life! Need help? The next two articles in the series, Care Coordination and Supporting Patient Self-Management and Care Coordination: Managing your Population will help you begin to construct the patient care experience of your care coordination program.


Agency for Healthcare Research and Quality (AHRQ), March 2008, Designing and Implementing Medicaid Disease and Care Management Programs: A User’s Guide.

Carrier E, Dowling MK, Pham HH. Care coordination agreements, facilitators and lessons learned. American Journal of Managed Care. 2012; 18:e398-404

Griffiths, J., Maggs, H., George, E.  Stakeholder Involvement. World Health Organization. September 2008.

Hall, Mark. A. The Commonwealth Fund, pub 1501 Vol 7, May 2011. Risk Adjustment Under the Affordable Care Act: A Guide for Federal and State Regulators.

Peikes D, Chen A, Schore J, Brown R. Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries15 Randomized Trials. JAMA. 2009;301(6):603–618. doi:10.1001/jama.2009.126

The Centers for Medicare & Medicaid Services (CMS), Connected Care: The Chronic Care Management Resource.


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