Importance

Health care in the United States is often fragmented. Clinical services are frequently organized around small groups of providers functioning autonomously and specializing in specific symptoms or organ systems. Therefore, many patients receive attention only for individual health conditions rather than receiving coordinated care for their overall health. For example, the typical Medicare beneficiary sees two primary care providers and five specialists each year.1 Communication of important information among providers and between providers and patients may entail delays or inaccuracies or fail to occur at all. Care coordination is a conscious effort to ensure that all key information needed to make clinical decisions is available to patients and providers. It is defined as the deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate appropriate delivery of health care services.2 It is multidimensional and essential to preventing adverse events, ensuring efficiency, and making care patient centered.3 Patients in greatest need of care coordination include those with multiple chronic medical conditions, concurrent care from several health professionals, or many medications and patients undergoing extensive diagnostic workups or transitions from one setting of care to another. Effective care coordination requires well-defined multidisciplinary teamwork principled on the notion that all who interact with a patient must work together to ensure the delivery of safe, high-quality care