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.

Related findings:

  • Care often is poorly coordinated across different settings and providers. In one survey, roughly 25 percent of patients noted that a test had to be repeated because the results from another provider had not been shared (see also Chapter 3).
  • Inadequate, sometimes absent, continuity of care endangers patients. Almost one-fifth of hospitalized Medicare patients are rehospitalized within 30 days, often without seeing their primary care provider in the interim (see also Chapter 3).
  • Although results for care coordination programs are mixed, there are effective interventions for improving care transitions. For example, the Care Transitions Model has been shown to reduce readmissions by 17 percent and costs by 50 percent.
  • Comprehensive health care requires accounting for factors typically outside of the traditional health care system. Most determinants of health lie outside of health care, with health care accounting for only 10 to 20 percent of health prospects. Thus there is a clear need for close clinical-community coordination.


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