Care coordination in primary care involves deliberately organizing patient care activities and sharing information among all participants concerned with a patient’s care to achieve safer and more effective care.
The main goal of care coordination is to meet patients’ needs and preferences in delivering high-quality and high-value health care. This means that the patient’s needs, and preferences are known and communicated at the right time to the right people. This information is used to guide the delivery of safe, appropriate, and effective care.
Examples of specific care coordination activities include:
- Establishing accountability and agreeing on responsibility.
- Communicating/sharing knowledge.
- Helping with transitions of care.
- Assessing patient needs and goals.
- Creating a proactive care plan.
- Monitoring and follow-up, including responding to changes in patients’ needs.
- Supporting patients’ self-management goals.
- Linking to community resources.
- Working to align resources with patient and population needs