Coordinated care synchronizes health services from various providers to enhance patient outcomes and reduce costs by eliminating redundant procedures. Effective population health management benefits patients, doctors, health organizations, and the entire healthcare system by improving care engagement and filling service gaps. Different coordination models, such as guided primary care and acute care coordination, are crucial for managing chronic and critical health issues, respectively, while addressing the complexities of post-acute care for aging patients.

2. Coordinated Care
Care coordination synchronizes the delivery of a patient’s health care from multiple
providers and specialists. The goals of coordinated care are to improve health outcomes by
ensuring that care from disparate providers is not delivered in silos, and to help reduce health
care costs by eliminating redundant tests and procedures.
Benefits of Coordinated Care
Effective population health management benefits patients, physicians, health care
organizations, the entire health care system, and the nation at large. Here’s how:
●Patients receive better coordinated care – and enjoy better health – because they are
reminded of procedures needed to manage their condition or disease.
●Physicians are better informed and their patients are more engaged, resulting in better
outcomes in care. Physicians also more easily satisfy quality measures that focus on engaging
patients and providing timely, appropriate, coordinated care.
●Health care organizations are more profitable – whatever their payment model – because
gaps in care are filled, patient volume increases and the cost of delivering care can be more
accurately quantified.
●The nation benefits from reduced health care costs, better management of diseases, and a
generally healthier population.
Examples Of Care Coordination
1. Primary care coordination
To care for patients with chronic diseases and conditions such as diabetes and high cholesterol,
some providers have adopted a “guided primary care” approach. The Guided Care model was
developed by a team of researchers at Johns Hopkins University, to respond to the challenge of
caring for a rapidly aging America. A specially educated, registered nurse (RN) is responsible for
patients with multiple chronic conditions. The RN performs an initial assessment with the

3. patient, works directly with the primary care providers to develop a care plan, and coordinates
specialty care with other providers to ensure that nothing is missed and the plan is followed.
2. Acute care coordination
Patients with acute health problems like a stroke or heart attack require a more complex level
of care due to the critical nature of their condition. Because emergencies like strokes and heart
attacks can happen anytime, patients may first receive care by emergency medical services and
by hospitals outside of their regular network. The risk for communication breakdowns,
redundancies, and medical errors can increase when providers are involved, making it even
more important that health care be coordinated to achieve the best clinical results. Studies
show that acute care coordination focusing on communication between provider-handoffs is an
important factor for success.
3. Post-acute/long-term care coordination
Patients who reside in rehabilitation, long-term care (LTC) or post-acute care (PAC)
facilities may need to move between facilities — or to different care levels within facilities — as
their health changes.A majority of patients admitted to PAC are later transferred to a second
PAC setting. These predominantly senior-aged patients often have mental and memory
disorders in addition to physical ones. They therefore require coordinated care to manage
medications transfers and update care plans. The importance of this is increasing as studies
show that hospital discharges to post-acute care (PAC) facilities have increased rapidly and
hospital readmission from PAC facilities is common and associated with a high mortality rate.
Readmission risk factors may signify inadequate transitional care processes or a mismatch
between patient needs and PAC resources.
Successes and failures in care coordination will be perceived in different ways
depending on the perspective: patient/family, health care professional(s), or system
representative(s). Consideration of views from these three potentially different perspectives is
likely to be important for measuring care coordination comprehensively.