• community-based interventions to improve health outcomes, including strategies related to the assessment and use of web-based tools.
  • Public and private payers should incorporate population health improvement into their health care payment and contracting policies and accountability measures.
  • Health economists, health service researchers, professional specialty societies, and measure development organizations should continue to improve measures that can readily be applied to assess performance on both individual and population health.

For many patients, care can be fragmented and uncoordinated, whether they are transitioning from the hospital to a community setting or between two different clinicians. As patient needs have grown more complex, focusing on coordination and communication across all of a patient’s health care providers has become increasingly crucial. These coordination and communication needs may be more acute when patients require services beyond the traditional health care system, such as social and community services, for managing their condition. Recommendation 6 outlines actions that need to be taken to improve care transitions and coordination to provide seamless care for patients.

Recommendation 6: Care Continuity

Improve coordination and communication within and across organizations. Payers should structure payment and contracting to reward effective communication and coordination between and among members of a patient’s care team.

Strategies for progress toward this goal:

  • Health care delivery organizations and clinicians, partnering with patients, families, and community organizations, should develop coordination and transition processes, data sharing capabilities, and communication tools to ensure safe, seamless patient care.
  • Health economists, health service researchers, professional specialty societies, and measure development organizations should develop and test metrics with which to monitor and evaluate the effectiveness of care transitions in improving patient health outcomes.
  • Public and private payers should promote effective care transitions that improve patient health through their payment and contracting policies.


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