Care Coordination

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Care Coordination is a deliberate process involving organizing and sharing information and activities among all the participants in patient care with the goal of achieving safer and more effective outcomes. From the patient perspective, the goal is to understand the patient's needs and preferences and well as the healthcare infrastructure so high-value care can be optimized, delivered, and utilized. From the provider and system perspective, the goal of care coordination is to help patients effectively navigate the healthcare system and for the system itself to provide effective and high quality care which leads to improved outcomes in both health and cost.

How is Care Coordinated?

The Agency for Healthcare Research and Quality has highlighted a number of activities that are involved in the process of care coordination:

  • 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

The goal is to utilize the available resources of the patient, community, and healthcare infrastructure to serve the patient's needs and preferences.

Why is Care Coordination Important?

The Role of Informatics

Submitted by (Tony Zhou)