Table 5Definitions for care coordination and related concepts

AAP 199913 “Care coordination is a process that links children with special health care needs and their families to services and resources in a coordinated effort to maximize the potential of the children and provide them with optimal care.” (1999)
AAP 200568 “Care coordination is a process that facilitates the linkage of children and their families with appropriate services and resources in a coordinated effort to achieve good health.” (2005)
Allred 199589 “Coordination is the ability to achieve the requisite unity of effort or teamwork across individuals, departments, and organizations so that the activities necessary for the organization's success do not go unperformed. Coordination implies collaboration or an integration of efforts, of which communication among individuals and groups is the basis.”;“Coordination is the technique used to satisfy the information needs of the numerous and diverse providers (differentiation) that are required to contend with patient care problems that arise in a complex, rapidly changing, unpredictable, and uncertain practice environment.” (citing Charns 1976)
Allred 199590 “Coordination refers to the regulation of activity between the nurse and the case manager so that necessary patient activities do not go unperformed” (citing Charns 1976)
Bickell 200191 “We developed a conceptual framework that posited 6 dimensions of coordination for early-stage breast cancer: standardization of work, feedback mechanisms, patient support, monitoring the quality of care, information systems, and location of care sites.”
Bodenheimer 199992 “The PCP [primary care practitioner] as coordinator assists patients in receiving the full range of medical services from the multitalented team of specialists and other caregivers”
Bolland 199493
  • “Coordination is a term that is often used without any exact referent, and in some cases, researchers report lack of coordination without either (a) indicating an empirical basis for their conclusions, or (b) indicating what empirical findings they would accept as evidence of coordination”;
  • “Integrative coordination”: “when the interorganizational system is structurally fragmented, coordination is low; when it is structurally integrated, coordination is high”
Brown 200442 “The term ‘care coordination’ has no well-established definition. Rather, it is generally understood to mean a process of improving communication among the various medical professionals with whom patients come in contact and between these professionals and the patients themselves (and their families).”
Cassady 200094 “Coordination addressed only the actual integration of services between a primary care provider and specialty care, because consumers might not know the characteristics of the practice (structure) that facilitate coordination of care”
Chen 200032
  • “There does not seem to be a clear, universally accepted definition of coordinated care for chronic illness.”
  • “Coordinated care programs, by our definition, are those that target chronically ill persons ‘at risk’ for adverse outcomes and expensive care and that meet their needs by filling the gaps in current health care. They remedy the shortcomings in health care for chronically ill people by (1) identifying the full range of medical, functional, social, and emotional problems that increase patients' risk of adverse health events; (2) addressing those needs through education in self-care, optimization of medical treatment, and integration of care fragmented by setting or provider; and (3) monitoring patients for progress and early signs of problems. Such programs hold the promise of raising the quality of health care, improving health outcomes, and reducing the need for costly hospitalizations and medical care.”
Cooley 200395 Coordination themes: role definition, family involvement, child and family education, assessment of needs/plans of care, resource information and referrals, advocacy
Fletcher 198496
  • Coordinated care components: “written evidence that the other physician was aware of the primary physician's involvement, and that 1) the primary physician arranged visit to the other physician or knew about it beforehand; or 2) the primary physician was aware of the patient's visit to the other physician after the visit”
  • Fletcher et al. “did not consider these components acts of coordination in themselves, but rather conservative markers of the coordinating process.”
Flocke 199897 “Coordination of care refers to the incorporation of information from referrals to specialists and previous health care visits into the current and future medical care of the patient.”
Flocke 199798 “Coordination of care is defined as the patients' perception of their physician's knowledge of other visits and visits to specialists, as well as the follow-up of problems through subsequent visits or phone calls.”
Forrest 200099 “Optimal coordination involves the documentation of patient care activities, interprovider communication, and the integration of service delivery into a single medical home” (citing Institute of Medicine 1996100 and Starfield 1998101)
Gilbert 1995102 “Coordinated care is a multi-disciplinary approach that focuses on achieving patient outcomes within effective time frames which have been established by all members of the health care team involved in the treatment of specific patient populations. The key to this model is the development of critical paths which serve as a guideline for interventions to be accomplished to achieve the desired outcome. Deviations from the critical path are documented and analyzed to determine system issues. An assigned coordinator is responsible for initiating the critical paths and monitoring patient progress.”
Gittell 2000103 “Relational co-ordination: co-ordination carried out by front-line workers with an awareness of their relationship to the overall work process and to other participants in that process. Relational co-ordination is characterized by frequent, timely problem solving communication and by helping, shared goals, shared knowledge, and mutual respect among workers. It is essentially a network of communication and relationship ties among workers, and can be thought of as a form of organizational social capital likely to enhance organizational performance.”
Gittell 2002104 “Coordination may be facilitated by certain design elements but it is more fundamentally a process of interaction among participants...Relational coordination reflects the role that frequent, timely, accurate, problem-solving communication plays in the process of coordination, but it also captures the oft-overlooked role played by relationships...specifically, coordination is carried out through relationships of shared goals, shared knowledge, and mutual respect.”
Gittell 2004105 Coordination is an “activity that is fundamentally about connections among interdependent actors who must transfer information and other resources to achieve outcomes”
Glasgow 2005106 Follow-up/Coordination: “Arranging care that extends and reinforces office-based treatment, and making proactive contact with patients to assess progress and coordinate care”
Guastello 2005107 “Coordination occurs when two or more people do the same or complementary tasks simultaneously.”
Healey 2004108 “Coordination refers to a team's performance enhancement of function through managing and timing activities and tasks.”
Hoenig 2001109 “Coordination of care was measured according to (a) number of different staff meetings, b) how often the therapists at team meetings (rounding therapists) were the same therapists treating the patient (treating therapists) versus someone providing a report from the treating therapist, and (c) use of paid escorts to transport patients to therapy.”
IOM 1996100 “Coordination ensures the provision of a combination of health services and information that meets a patient's needs and specifically means the connections within and across those services and settings - putting them in the right order and appropriately using resources of the community. The goal is to focus on interactions with patient and family and their health concerns, clarify clinical care decisions, advise hospitalized patients and their families, and help patients and their families cope with the social and emotional implications of disease or illness.”
IOM 2004110 “To establish and support a continuous healing relationship, enabled by an integrated clinical environment and characterized by the proactive delivery of evidence-based care and follow-up. Clinical integration is further defined as the extent to which patient care services are coordinated across people, functions, activities and sites overtime so as to maximize the value of services delivered to patients. Coordination encompasses a set of practitioner behaviors and information systems intended to bring together health services, patient needs, and streams of information to facilitate the delivery of care in accordance with the six aims set forth in the Quality Chasm report. Such coordination can be facilitated by procedures for engaging community resources, including social and public health services.” (synthesized from several sources2, 6, 111)
Kibbe 2001112 Care coordination is a term that encompasses a variety of care management methods - from case to disease management - that aim to improve the quality of care provided to patients with chronic illness while decreasing avoidable costs associated with their coordination is viewed by its practitioners (mostly specially trained nurse case managers) as a method for decreasing the fragmentation of health delivery sites and, through better planning and monitoring of patient care plans, ending the confusion and uncertainty that often attend care for patients with complicated illnesses or multiple medical problems. Care coordination also is a means to increase the likelihood that patients with chronic illness will achieve recommended care and adhere to best practices for specific illnesses and conditions. Finally, care coordination is a collaborative and team approach that recognizes the importance of keeping the attending physicians informed while enhancing information sharing and communication among providers so as to maintain a fabric of continuity.”
Kinsman 2000113
  • “[Coordination] pertains to the systems aspect of the service delivery system.”
  • “[Coordination requires models of team functioning. The complexity of spina bifida...requires the perspectives, knowledge bases and skills of a wide variety of professionals. How these different groups work together and integrate is what comprises [coordination].”
Kodner 2002114 Coordination, the middle ground in integrated care, entails the development of formal structures and mechanisms to bridge the gap between providers and institutions, as well as work around system weaknesses and barriers, without fundamentally changing these systems per se. A variety of techniques are employed, including uniform assessment procedures, care management, joint care planning, team care, standardized guidelines and protocols, and common clinical and service records.”
Lima & Brooks 1985115 Assessment of coordination between medical and community mental health center: “Coordination of care with the [community mental health center] was noted as present if a telephone call, or letter, or a review of the psychiatric chart had taken place...coordination with the medical clinic could have taken place through a telephone call, a letter, or a review of the medical chart.”
Longest & Klingensmith 1994116
  • “Conceptually and historically, coordination has been defined as the conscious activity of assembling and synchronizing differentiated work efforts so that they function harmoniously in attainment of organization objectives.”
  • Extending the definition to encompass both inter- and intraorganizational situations: “coordination is conscious activity aimed at achieving unity and harmony of effort in pursuit of shared objectives within an organization or among a set of organizations participating in a multiorganizational arrangement of some kind.”
Malone & Crowston 1994117 “Coordination is managing dependencies between activities.”
Massachusetts Consortium for Children with Special Health Care Needs Care Coordination Work Group 2006118 “Care coordination is a central component of an effective system of care for children and youth with special health care needs and their families. Care coordination is an ongoing process which engages families in development of a care plan and links them to health and other services that address the full range of their needs and concerns. Principles of care coordination reflect the central role of families and the prioritization of child and family concerns, strengths and needs in effective care of children with special health care needs. Activities of care coordination may vary from family to family, but start with identification of individual child and family needs, strengths and concerns, and aim simultaneously at meeting family needs, building family capacity and improving systems of care.”
McGuiness & Sibthorpe 2003119 “We conceived of coordination as a complex construct, incorporating both overall impacts of care as well as discrete key processes. Questionnaire items were designed to capture aspects of coordination that were grouped into six domains: identification of need, access to care (drugs, tests or imaging, and services); patient participation, including empowerment; patient-provider communication; inter-provider communication; and global assessment of care.”
National Quality Forum 2006120 “Care coordination is a function 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. Coordination maximizes the value of services delivered to patients by facilitating beneficial, efficient, safe, and high-quality patient experiences and improved healthcare outcomes.”
Ohlinger 2003121 Coordination components: communication, multidisciplinary input, consistency in practice
Parchman 2005122 “Coordination of care refers to the degree to which information from various sources is incorporated by the physician into the care the patient receives.”
Parkerton 2004123 “Practice Coordination” is referred to as “system continuity”
Pollack 2003124 Coordination construct: “Degree to which relationships with other units in the hospital facilitate ICU performance”
Reid 2002125
  • “The core element of the interaction between an individual and health care providers helps distinguish continuity from other concepts that are often used synonymously. For instance, if the focus is on the interaction among providers, then the concept reflects co-ordination and integration not continuity. As [the] Director of Research at the Alberta Mental Health Board ... said, ‘Continuity is how patients experience co-ordination between providers.’”
  • Management continuity refers to “the provision of separate types of healthcare over time in ways that complement each other so required services are not missed, duplicated or poorly timed.”
  • “Although co-ordination refers specifically to the interaction between providers - and thus is not strictly continuity - it should result in the patient sensing ‘management continuity’, which means the care received from different providers is connected in a coherent way.”
  • Management “continuity is measured by the extent to which care is given in the correct sequence, at the proper time and in the clinically appropriate manner.”
Rosenbach & Young 200050
  • “There is no standard definition of care coordination.”
  • “Care coordination programs tend to use a broader social service model that considers a patient's psychosocial context (such as housing needs, income, and social suppor may coordinate a full range of medical and social support services offered within and outside the managed care plan...typically arrange covered and non-covered services for patients.”
Shortell 1994126 “Coordination refers to the extent to which functions and activities both within the unit and between units are brought together in a way that promotes cost-effective continuous care.” (citing Longest & Klingensmith 1994116)
Sprague 2003127 “All of these concepts [disease management, case management, care coordination, care management] have in common the principle of getting a person clinically appropriate care in a timely manner without wasting resources. Care coordination seeks primarily to help a patient navigate the system, working across care settings and providers and frequently accessing other services, such as personal care or community programs, as well.”
Starfield 1979128 “Coordination of care was defined as the recognition of information (problems, therapies, intervening visits and tests) about patients from one visit to a follow-up visit.”
Temkin-Greener 2004129 “The degree to which: work activities within a team are coordinated through formal plans, protocol, schedules; and face to face interactions are perceived as effective.”
U.S. Department of Veterans Affairs Office of Care Coordination 84 (Accessed August 29,2005)“Care coordination in VHA is the wider application of care and case management principles to the delivery of health care services using health informatics, disease management, and telehealth technologies to facilitate access to care and improve the health of designated individuals and populations with the intent of providing the right care in the right place at the right time”
Van de Ven 1976130 “Coordination means integrating or linking together different parts of an organization to accomplish a collective set of tasks.”
Wehr 2000131
  • “No validated measure of the quality of care coordination exists. Indeed, there is no single, generally accepted definition of ‘care coordination’.”
  • “Care coordination was ‘opening doors’ to needed services for Medicaid enrollees and helping them with non-medical problems that could compromise their health.”
  • “The purpose of care coordination is to assist persons with special health care needs and their families gain access to services covered under their Medicaid managed care plan and to other services available in their communities.”
  • “Care coordination is support by an information system dedicated to care coordination and linked to other MCO information systems...requires a written plan of care based on a comprehensive assessment of the goals, capacities, and medical condition of the consumer and the needs and goals of family caretakers...includes monitoring to assure that services are received, to identify problems in the quality of care, to reassess and revise care plans, and to advocate on behalf of enrollees and family caretakers.”
Wenger 2004132 Coordination is a “'process by which the elements and relationships of medical care during any one sequence of care are fitted together in an overall design....coordination involves the sharing of information about past findings, evaluation, and decisions, and the use of these in current management, among a number of providers to achieve a coherent scheme of management” (citing Donabedian 1980133); “matching the patient's needs with the appropriate level and type of medical, health, and social services” (citing JCAHO134)
Young 1998135 “Coordination has been defined as the conscious activity of assembling and synchronizing differentiated work efforts so that they function harmoniously in attainment of organizational objectives.” (citing Haimann & Scott 1990)

From: 3, Definitions of Care Coordination and Related Terms

Cover of Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination)
Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination).
Technical Reviews, No. 9.7.
McDonald KM, Sundaram V, Bravata DM, et al.

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