Adrienne Mann

19 Feb, 2021
Follow Coleman!

Adrienne Mann

19 Feb, 2021
Follow Coleman!

Care Coordination Guide


According to the Agency for Healthcare Research and Quality, Care Coordination is “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 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” (2019).

Care Coordination is something that some health centers and primary care medical practices have been doing for years while others have just begun to delve into the possibilities. Coleman Associates has been working with healthcare providers who are all along the Care Coordination spectrum. Some have a large Care Coordination staff and concretized strategy, others are still working on getting uninhibited access to their patients records outside of the health center for their primary care patients. Regardless of where an organization is, working to improve Care Coordination greatly benefits patients, staff, and the bottom line of the organization as the US moves toward value-based payment in healthcare.

About This Guide

This toolkit is meant to serve as a guide for healthcare providers and organizations who are starting or honing their Care Coordination framework.  We have compiled tools, advice, workflows and best practices from health centers across the country and they are represented in this toolkit. We have also linked to external trusted resources to serve as other examples that you can shamelessly steal as you make your Care Coordination process work for your patients and staff.

Social Determinants of Health and Care Coordination

Many organizations are taking a hard look at how to prevent hospitalization and emergency department use and how to smooth the transition from higher levels of care to outpatient services. This is critical work in improving the quality of life for patients and communities in addition to reducing the cost of healthcare overall. When imagining and building these systems for improved healthcare, it is important to remember the gross disparities that exist between communities in healthcare already. The purpose of this guide is not to detail all of these disparities. To read more about health disparities, the Healthy People framework is a good place to start.

The importance of keeping these disparities in mind while building a Care Coordination system is that because of these disparities, the people who need Care Coordination the most are often the people who are hardest to care coordinate. For example, a patient that has many hospital and emergency department visits, may also not have a working phone and is difficult to contact. The social determinants of health that make that patient high risk for hospital and emergency department (ED) visits also make them likely to not have access to a stable phone number or living situation.

It is likely much easier to build a Care Coordination program that can do a great job of reaching patients with high incomes and fewer social determinants of health. Reaching these higher income patients is important work because patients of all backgrounds deserve well-coordinated healthcare. The more challenging, critical task is to create a Care Coordination program that can truly reach all patients, regardless of income and social determinants of health, so that it doesn’t reinforce and worsen existing disparities.

Practice Redesign and Care Coordination

Before creating a new Care Coordination Department, consider the impacts of the day to day operational challenges in a health center on Care Coordination. Lack of meaningful access to primary care is a key driver of hospitalizations and emergency department visits.

Care Coordination in the Clinic

The tendency when building a Care Coordination program is to focus first on transitions of care (the movement of a patient from one healthcare setting to another). This makes sense because there is often grant funding or quality bonuses associated with transitions of care for organizations. Transitions of care are certainly critical to patient safety and health (2018), but great care starts well before a patient goes to the emergency department or hospital. Great care coordination starts in outpatient health care because of the opportunity to prevent many of the hospital and emergency visits before they happen. The following are areas to focus on in the clinic.

Patient Care Teams

The first step in having a comprehensive Care Coordination system for patients is to have consistent Patient Care Teams in the clinic. This means that for a given panel of patients, there is a relatively consistent group of staff members caring for that panel. These Patient Care Teams have many different possible combinations. The most common is at least one Medical Provider, a support staff member like a Medical Assistant or a Nurse, and a front desk staff member. Depending on the productivity of the team, the organization may share staff members between multiple Medical Providers. Teams may also include Behavioral Health staff, Dental Staff, Interpreters, etc. When Patient Care Teams work together consistently, they get to know their patients. Familiarity with the patient panel can help teams to make more “good catches” on quality measures and increase the patients’ trust of their healthcare.

Embedding Care Coordination in the Team

Some organizations choose to hire specific “Care Coordinators.” Depending on the organization these Care Coordinators can be nurses or laypeople. This decision depends on the patient population’s needs. Other organizations have existing support staff complete Care Coordination work such as getting records from specialists and hospitals, processing referrals, and outreaching patients that are overdue for quality metrics. Some organizations have a combination of these methods. A critical step to making Care Coordination work possible and highly effective is to embed whoever is doing Care Coordination work into the Patient Care Team as mentioned above. This allows the care coordinator to get to know the patients in the panel and to utilize the whole team to engage the patients. Embedding the care coordinator in the team also makes outreach simpler and more efficient because it’s possible to catch some patients while they are being seen in the clinic or via telehealth by the team.

In some instances, care coordinators are paid for by particular payors and may have to straddle more than one patient care team as they work to care for a subset of the team’s patients (the subset that belongs to the unique payor). In this case, building relationships with the patient panel is still possible, but it may require that care coordinators join multiple Patient Care Teams for huddles and throughout the day to catch these patients.

Patient Care Team Example 1

Patient Care Team Example 2

Patient Care Team Huddles

A critical tool for communication of Patient Care Teams, including care coordinators is the Patient Care Team huddle. This article provides more information about creating great Patient Care Team huddles. Getting everyone on the Patient Care Team to have a daily or twice daily conversation about the patients helps the whole team to be on the same page and to catch any patient needs that may otherwise be missed. Really savvy teams, or really savvy care coordinators, also use the last few minutes of the huddle to talk about patients that DO NOT have an appointment on today’s schedule.  Care Coordinators may bring up patients from the patient panel that were recently hospitalized or had an emergency department visit. They may also bring up patients that they are having trouble reaching. This allows the whole team to be aware of patients that may be falling through the cracks and strategize about how to keep them safe and healthy.


Outreach for patients when Care Coordination is embedded in the Patient Care Team falls into two categories: patients who have appointments and patients who do not have appointments.

Getting Records

Getting records for patients from specialists, long-term care facilities, emergency departments, or hospitals often requires diligent process design for the Patient Care Team. The following are key times to ask about records and request them to minimize the number of missing records for patients:


Carefully reconciling medications and helping patients to understand their medications can significantly reduce the risk of poor health outcomes and repeat hospitalizations for patients. The following details the steps in the process of seeing patients to help patients understand and adhere to medication regimens:

Transitions of Care

Transitions of care are some of the highest risk health events for patients and can be tricky for Patient Care Teams and care coordinators to coordinate. The ideal situation is to have Care Coordination staff embedded in the hospital or emergency department. This is not always possible, and often organizations have more than one hospital that patients use, which still requires a strong coordination process for other hospitals.

The first step in coordinating transitions of care is to know when patients use the hospital or emergency department. Usually organizations need several ways to get this information to minimize the number of missed hospitalizations and ED visits. One simple, low cost way to do this is educate patients about notifying the Patient Care Team if they go to the hospital. The following is an example of a business card that Patient Care Teams can hand out to patients.

Education for patients can also include a method for contacting the clinic with medical questions such as an after-hours line or nurse line. Make sure to stress to patients that they shouldn’t delay emergency care to reach the clinic. Let them know that if they aren’t sure if they should go to the Emergency Department, urgent care, or the clinic that they can easily reach a medical professional at the clinic to ask for advice (and then ensure that that process is easy for a patient to reach someone with questions).  If the patient does need to go to a higher level of care than the clinic can offer, make sure that this information gets back to the Patient Care Team.

Getting information directly from hospitals or other acute care facilities is an additional way to get a notification when patients are in the hospital. This requires building relationships with local hospitals and service providers and creating processes for receiving these notifications. Options for sending this information could include a care coordinator joining the hospital’s rounds in-person or virtually or receiving a secure email with a list of patients that came in overnight. Make sure that this information is communicated back to the Patient Care Team.

Ideally, the Patient Care Team will receive a notification before the patient leaves the hospital. If this happens, the Patient Care Team should make every effort to reach out to the patient or the providers in the hospital to get more information.

Even if you don’t have a formal communication process with hospital staff, try calling the hospital and asking to be transferred to the patient’s room. You may even be able to catch the patient’s nurse or hospital care coordinator on the phone.

Use a checklist for transitions of care to make sure the patients’ needs are met. Start this checklist before the patient leaves the hospital when possible. The following is an example checklist (and may not include all of the details necessary for your health center):

Working with Community Partners

Working with community partners, specifically hospital partners, is critical to setting up a smooth transition of care system for patients. This is an ongoing process that requires leaders from both organizations to commit to the success of the coordination. Some of the first steps in setting up a coordinated system is to get the stakeholders together in-person or virtually to discuss the process. Identify point people for this process and come up with action plans to move the process forward. The following is a series of discussion questions to guide these meetings of stakeholders.


Care Coordination is a multi-faceted, ongoing process of providing better care to a population of patients. Regardless of where an organization is starting from, there is always an opportunity to improve Care Coordination and to improve the health outcomes of patients. Care Coordination work is critical for the health of patient populations and in the transition to value-based payment for health care.



Care Coordination. AHRQ. (2019, August).

Reedy , A. B., Yeh, J. Y., Nowacki, A. S., &; Hickner, J. (2016, March). Patient, Physician,

Medical Assistant, and Office Visit Factors Associated With Medication List Agreement.

Journal of patient safety.

Third Next Available Appointment: IHI. Institute for Healthcare Improvement.

Transitions of Care. Agency for Healthcare Research and Quality. (2018, June).




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