National Healthcare Disparities Report - LDI Health Economist

Chapter 6. Care Coordination
Health care in the United States is often fragmented. Clinical services are frequently organized around small
groups of providers who function autonomously and specialize in specific symptoms or organ systems.
Therefore, many patients receive attention only for individual health conditions rather than receiving
coordinated care for their overall health. For example, the typical Medicare beneficiary sees two primary care
providers and five specialists each year (Bodenheimer, 2008). Communication of important information
among providers and between providers and patients may entail delays or inaccuracies or fail to occur at all.
Care coordination is a conscious effort to ensure that all key information needed to make clinical decisions is
available to patients and providers. It is defined as the deliberate organization of patient care activities
between two or more participants involved in a patient’s care to facilitate appropriate delivery of health care
services (Shojania, et al., 2007). Care coordination is multidimensional and essential to preventing adverse
events, ensuring efficiency, and making care patient centered (Powell-Davies, et al., 2008).
Patients in greatest need of care coordination include those with multiple chronic medical conditions,
concurrent care from several health professionals, many medications, and extensive diagnostic workups, or
transitions from one care setting to another. Effective care coordination requires well-defined
multidisciplinary teamwork based on the principle that all who interact with a patient must work together to
ensure the delivery of safe, high-quality care.
In early 2011, the Partnership for Patients was created to improve the quality, safety, and affordability of
health care for all Americans. One of the two major goals of this public-private partnership is to heal patients
without complications arising. This goal specifically ties to care coordination by seeking to decrease
preventable complications during transition from one care setting to another. The objective is to decrease all
hospital readmissions by 20% overall by the end of 2013 (compared with 2010).
One example of the Federal Government’s efforts to support care coordination is the Health Resources and
Services Administration’s (HRSA) initiative “Enhancement & Evaluation of Existing Health Information
Electronic Network Systems for PLWHA (People Living with HIV/AIDS) in Underserved Communities.”
Begun in 2007, the initiative funded six demonstration sites throughout the Nation for up to 4 years. i
Another more recent funding opportunity also offered by HRSA is “Systems Linkages and Care Initiative to
High Risk Populations Evaluation and Technical Assistance Center.” This initiative promotes the development
of innovative strategies to successfully integrate different components of the public health system into quality
HIV care of hard-to-reach populations who have never been in care. AHRQ intends this chapter to be the
leading step in the evolving national discussion on measuring care coordination. Furthermore, AHRQ hopes
that this chapter will stimulate productive discussions in the area of care coordination, including development
and use of valid, reliable, and feasible quality measures.
i For more information, see: http://hab.hrsa.gov/abouthab/special/underservedcommunities.html.
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