Successful care coordination models also utilize care coordinators to work with identified patients in formulating care plans that advance the patients’ life and health goals and to coordinate services, including social services and health provider services, to meet those goals. Care coordinators may be nurses, social workers, other health workers, or lay people as long as they have the skills to communicate with and motivate their patients, coordinate a broad range of services, and do all that is necessary to prevent negative outcomes (Bradway et al., 2011). New types of health care professionals also have been introduced to coordinate care in many health care settings; an example is the increasing use of hospitalists to coordinate care in inpatient visits (Meltzer and Chung, 2010; Meltzer et al., 2002).
Conclusion 7-2: Coordination and integration of patient services currently are poor. Improvement in this area will require strong and sustained avenues of communication and cooperation between and among clinical and community stewards of services.