Milestone 14 Summary

Description: Practice clearly defines care coordination roles and responsibilities and these have been fully implemented within the practice.

What does success look like?


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Practice has not developed its approach to providing care coordination for its patient population.
Practice has a plan for care coordination, but it has yet to be formally documented in writing or translated to specific roles and responsibilities within the practice. Practice has developed the job descriptions and roles and responsibilities for care coordination but these have not been fully implemented. The practice vision for care coordination is fully documented and fully implemented.

Note: numbers are PAT scores

Why is this important?

A well thought out plan for care coordination is necessary for busy practices. Care coordination is the “deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services.”1  Care coordination allows you to plan and distribute resources in strategic and effective ways that maximize staff time and provide assistance to patients with the greatest needs. Care coordination activities may include a range of strategies necessary for providing patient-centered, continuous care in the transformed practice, including but not limited to: patient risk stratification, clearly defining roles for team-based care, providing and tracking referrals, ensuring a process for sharing patient information between multiple providers, providing medication reconciliation and general system navigation.2 To get started, a practice may choose to develop its care coordination plan for a subset of cost-intensive, complex patients (e.g. patients with co-morbid chronic diseases, homeless patients, or high emergency department users) who would benefit from such intentional support services. In an increasingly fragmented healthcare system, care coordination is necessary to improve patient outcomes and satisfaction, reduce costs and waste, prevent avoidable hospitalization and emergency department use and operate an efficient practice.3

Potential Tactics

  • Determine care coordination job duties (e.g. pull data from EHR, assess patient needs, barriers and assets, review medication with patients, etc.) and how to incorporate into existing positions as possible.
  • Identify and train staff person to coordinate and document referrals (specialty, community, etc.) and approaches to assess and overcome patient barriers to obtaining referrals.
  • Add responsibilities into annual job reviews and job descriptions
  • Regularly talk with patients about other clinical encounters they have outside the practice (e.g. emergency department visits, hospitalizations, urgent care clinics, behavioral health providers, etc.) to ensure proper follow up and continuity of care.
  • Establish data sharing agreements and standardize information sharing processes with specialists, hospitals and community organizations within the medical neighborhood.
  • Incorporate lay people as community health workers to assist with follow-up calls, home visits and system navigation.

Tools and Resources

What might this look like in practice?

A primary care practice is focusing its care coordination services on patients with at least one chronic disease, a mental health condition and a history of medically unnecessary emergency department visits. The practice’s social worker serves as the main care coordinator and sits with each patient to screen for depression and to assess their social needs using a survey adapted from the PREPARE assessment tool. The social worker uses this information to talk with the patient about their social, legal and other needs, in addition to health needs. Referrals are made to community organizations as needed, including behavioral health agencies. The social worker tracks all referrals in an excel database, enters notes into the patients’ chart, and discusses the status of each patient with the primary care physician during morning huddles on days they have an appointment. Additionally, the social worker serves as a liaison with the local hospital and other groups to manage data sharing agreements. The practice receives notice when their care coordination patients are admitted to the ED or hospitalized and the social worker follows up with the patient to discuss their care plan, any barriers and additional support they may need, and general preventive measures and self-management skills that can be applied in the future. The practice is piloting this model with a caseload of 20 patients. They are also exploring the use of complex care management billing codes for reimbursement.


  1. McDonald KM, Sundaram V, Bravata DM, et al. Closing the quality gap: A critical analysis of quality improvement strategies, Volume 7—Care Coordination. AHRQ Publication No 04(07)-0051-7. 2007
  2. Horner K, Schaefer J, Wagner E. Care Coordination: Reducing Care Fragmentation in Primary Care. In: Phillips KE, Weir V, eds. Safety Net Medical Home Initiative Implementation Guide Series. 2nd ed. Seattle, WA: Qualis Health and The MacColl Center for Health Care Innovation at the Group Health Research Institute; 2013.
  3. Craig C, Eby D, Whittington J. Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs. Institute for Healthcare Innovation, Innovation Series 2011.