Care coordination

About care coordination

Care coordination is the deliberate integration of patient care activities between two or more participants involved in a person’s care, to facilitate the appropriate delivery of health care services.1

Patient care that is coordinated across professionals, facilities and support systems is:2

  • continuous over time and between visits
  • tailored to the individuals needs and preferences, and
  • based on shared responsibility between person and caregivers for optimising health.

Coordination of care is needed to support people with one or more chronic health conditions. It is most needed by people who are unable to manage the demands associated with accessing multiple service providers for care.

The intensity of coordination of care varies according to the complexity of a person’s care needs and their social, cognitive and mental health state. Coordination needs are dynamic and fluctuate over time – needs increase during periods of instability in a person’s illness and decrease once this instability passes.

Access to support for coordination of care must be timely, regardless of the intensity of a person’s coordination of care needs3.

The increasing prevalence of people with multiple chronic health conditions, known as multi-morbidity is a central part of the rationale for better coordinating care. The number of people living with two or more conditions is rising rapidly, meaning that multi-morbidity and the challenges it brings for coordination of care are increasingly becoming the norm.

Multi-morbidity is a more important driver of costs in the health and social care system than other factors such as age.4

The goal of coordinated care is to meet a person's needs and preferences in the delivery of high-quality, high-value health and community services. This means that the a person'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.5

  • 1. Taylor EF, Lake T, Nysenbaum J, et al. Coordinating care in the medical neighbourhood: critical components and available mechanisms. White Paper (Prepared by Mathematica Policy Research under Contract No. HHSA2902009000191 TO2). AHRQ Publication No. 11-0064. Rockville, MD: Agency for Healthcare Research and Quality, June 2011.
  • 2. Horner K, Scaefer J, Wagner E. Care coordination: Reducing care fragmentation in primary care, in Safety Net Medical Home Initiative Implementation Guide Series 2nd ed. 2013. Qualis Health and The MacColl Centre for Health Care Innovation at the Group Health Research Institute: Seattle, WA.
  • 3. KPH_A model for improving coordination of care_Revised_June 2016.pdf; Pg 6
  • 4. Ibid, Pg 11
  • 5. Ibid, Pg 11