Care coordination means different things to different people; no consensus definition has fully evolved. A recent systematic review identified over 40 definitions of the term "care coordination."² The systematic review authors combined the common elements from many definitions to develop one working definition for use in identifying reviews of interventions in the vicinity of care coordination and, as a result, developed a purposely broad definition: "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. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care." For some purposes, they noted that other definitions may be more appropriate. This lack of consensus is perhaps not surprising given the many different participants involved in coordinating care.

In this section we provide a visual definition (go to Figure 1) and scenarios to help illustrate care coordination in the absence of a consensus definition. This visual definition may be helpful to some Atlas users, and less so to others. Several additional illustrations of care coordination are presented in a recent monograph on quality of cancer care.

Why should the state department of health elaborate on the job description of the care coordinator?
Various resources are interpreting care coordinator differently. There has to be one standard job description of the care coordinator in the state in consultation with physicians of the state.

Perspectives on Care Coordination

Successes and failures in care coordination will be perceived (and may be measured) in different ways depending on the perspective: patient/family, health care professional(s), or system representative(s). Consideration of views from these three potentially different perspectives is likely to be important for measuring care coordination comprehensively.

Patient/Family Perspective. Care coordination is any activity that helps ensure that the patient's needs and preferences for health services and information sharing across people, functions, and sites are met over time.⁴

Patients, their families, and other informal caregivers experience failures in coordination particularly at points of transition. Transitions may occur between health care entities (see definition under "additional terms") and over time and are characterized by shifts in responsibility and information flow. Patients perceive failures in terms of unreasonable levels of effort required on the part of themselves or their informal caregivers in order to meet care needs during transitions among health care entities.

Health Care Professional(s) Perspective. Care coordination is a patient- and family-centered, team-based activity designed to assess and meet the needs of patients, while helping them navigate effectively and efficiently through the health care system. Clinical coordination involves determining where to send the patient next (e.g., sequencing among specialists), what information about the patient is necessary to transfer among health care entities, and how accountability and responsibility is managed among all health care professionals (doctors, nurses, social workers, care managers, supporting staff, etc.). Care coordination addresses potential gaps in meeting patients' interrelated medical, social, developmental, behavioral, educational, informal support system, and financial needs in order to achieve optimal health, wellness, or end-of-life outcomes, according to patient preferences.⁵

Health care professionals notice failures in coordination particularly when the patient is directed to the "wrong" place in the health care system or has a poor health outcome as a result of poor handoffs or inadequate information exchanges. They also perceive failures in terms of unreasonable levels of effort required on their part in order to accomplish necessary levels of coordination during transitions among health care entities.

System Representative(s) Perspective. Care coordination is the responsibility of any system of care (e.g., "accountable care organization [ACO]") to deliberately integrate personnel, information, and other resources needed to carry out all required patient care activities between and among care participants (including the patient and informal caregivers). The goal of care coordination is to facilitate the appropriate and efficient delivery of health care services both within and across systems.

Failures in coordination that affect the financial performance of the system will likely motivate corrective interventions. System representatives will also perceive a failure in coordination when a patient experiences a clinically significant mishap that results from fragmentation of care.⁶

Additional Terms. Definitions for additional terms relating to care coordination are presented below.

Health care entities. Health care entities are discrete units of the health care system that play distinct roles in delivery of care. The context and perspective will determine who precisely those units are. For example:

• From a patient and family perspective, entities are likely to be individual health care providers with whom the patient and family interact, such as nurses, physicians, and support staff.
• From a health care professional perspective, entities may be individual members of a work group, such as nurses, physicians, and support staff in a particular clinic. Or they may be provider groups, such as a primary care practice, specialty practice, or urgent care clinic.
• From a system representative(s) perspective, entities will likely be groups of providers acting together as a unit, such as medical units in a hospital, hospitals as a whole, specialty clinics within an integrated system, or different clinical settings within the health care system overall (i.e., ambulatory care, inpatient care, emergency care).

Points of transition. Transitions occur when information about or accountability/responsibility for some aspect of a patient's care is transferred between two or more health care entities, or is maintained over time by one entity. Often information and responsibility are (or should be) transferred together.

It may be useful to think about two broad categories of transitions:

1. Transitions between entities of health care system. Information transfer and/or responsibility shifts:
   • Among members of one care team (receptionist, nurse, physician)
   • Between patient care teams
   • Between patients/informal caregivers and professional caregivers
   • Across settings (primary care, specialty care, inpatient, emergency department)
   • Between health care organizations
2. Transitions over time. Information transfer and/or responsibility shifts:
   • Between episodes of care (i.e., initial visit and followup visit)
   • Across lifespan (e.g., pediatric developmental stages, women's changing reproductive cycle, geriatric care needs)
   • Across trajectory of illness and changing levels of coordination need

What have been various findings up to now?
A care coordinator in Chicago, Illinois, approached a resident through telephone call and email while communicating that some questions will be submitted via email. Suddenly, the care coordinator declares that she is quitting her job, making a total of 10 months that the specific resident remains without a healthcare provider. What are your plans to prevent such incidents?

Questions that need to be answered.

If the state’s (for example Illinois) department of health has a profile of residents, why does the care coordinator need to get profiles of residents again?

How do you ensure that a resident is not neglected while being assigned to a care coordinator?

If there are no physicians, specialist, or super specialists within walking distance of, for example, 5042 N. Winthrop Ave., Chicago, Illinois 60640, who has the duty to place competent physicians, specialist, or super specialist in the area from state department of health?

What are you doing to improve the quality of physicians/specialists/super specialists within walking distance in the community?

What is a care coordinator?
Why is a care coordinator required?
When is care coordinator useful?
What is expected of a care coordinator?
How can a care coordinator help doctor and residents?
Here are further guidelines.