What is Care Coordination?

Care coordination the way a care team develops and applies a well-organized, coordinated shared plan of care which integrates information and needed services across a patient's whole care team.

• It targets comprehensive care for individuals with complex needs, by assessing and addressing interrelated medical, social, developmental, psychological, behavioral, educational, environmental and financial needs.
• It allows the longitudinal care team to recognize health care needs and reduce acute care burdens.
• It anticipates and targets the vulnerabilities and complexities at transitions of care.
• Care coordination improves quality of life and satisfaction for patients and families as well as the satisfaction of the teams who serve them. It manages health care costs by using a proactive rather than reactive approach to care.

• Care management focuses on improving the health and well-being of patients with chronic conditions through more effective management.
• It helps individuals manage their chronic condition(s) and facilitates treatment plans to assure the appropriate clinical pathway is delivered.
• It is a comprehensive process that includes assessment of needs, planning and securing the most appropriate services.
• It usually acts at high-touch or episodic encounters to particularly target individuals with barriers to accessing care.
• Care management improves quality of care and satisfaction for patients and families. It manages health care costs by attending to standardized pathways as well as individualized actions to address the unique needs of each patient.

• Care navigation facilitates patient movement through systems of care most commonly at episodic, complicated points of contact.
• It advocates for and guides patients through system complexities to ensure they receive the right care at the right time.
• It directs patients to the correct clinician(s) and service(s) while understanding expected coverage of these services by the person’s insurance plan.
• It assesses potential barriers to care and directs patients to services which assist in overcoming these barriers.
• Care navigation improves quality of care and satisfaction for patients and families. It manages health care costs through use of the right services at the right time.

Care supports are specific processes which facilitate the delivery of appropriate care in specific circumstances of need across diverse populations of patients and families. They may involve coordination, management and/or navigation of care.

Care supports:

• identify appropriate persons to receive a service
• listen to those they serve
• assess their needs
• provide information to families about available services
• educate and empower those they serve
• facilitate delivery of appropriate services
• communicate key information effectively to necessary recipients
• advocate for the quality of families’ care and services

The overarching goal is to meet each patient needs and preferences in the delivery of high-quality and high-value care.