Coordinating Care In (and Outside) Your Practice

by Tom Ludwig, RN, MBA, FACMPE

According to a recent report of the Agency for Healthcare Research and Quality (AHRQ), the top 5% of users of healthcare services in the US account for 50% of all healthcare expenditures. Many of these people have chronic diseases, multiple medications and behavioral health issues. It shouldn’t be surprising that they receive care from many points across the continuum – inpatient, outpatient, and in the community. This sets the stage for potential problems before, during and after each episode of care. Such problems are related to poor communication of appropriate (and necessary) healthcare information, missed appointments and the lack of follow-up on test results and referrals. Not only does this impact the overall cost of care, it can also have a direct effect on outcomes.

How can physician practices effectively work with this population of patients? One of the answers is by providing care coordination. In the MGMA Connexion article “New to the Scene” (March 2012), Dr. Marjie Harbrecht explains that care coordinators ensure patients get needed services, track diagnostic test results and referrals, and manage the flow of medical information in and out of the office. The National Committee for Quality Assurance (NCQA) 2011 Patient Centered Medical Home Standards can be used as a reference for what a care coordinator can do. The Track and Coordinate Care Process Measures outline specific needs for test tracking and follow-up, referral tracking and follow-up, and coordinating with facilities and care transitions – especially hospital admissions and emergency department visits. (The NCQA process measures can be found at, care coordination tools and resources.)

Who can fill the role of care coordinator in your clinic? Dr. Harbrecht is careful to point out the difference between care coordination and care management. While care coordination focuses on the tactical issues of patient care, care management addresses the clinical and behavioral factors. This is an important differentiation to make, especially when deciding on how to staff. A care coordinator is more of a process/logistics person, while a care manager is responsible for making clinical judgment. Given this distinction, the care coordinator role can be filled by people with a variety of backgrounds. In many practices it is an experienced medical assistant. It can also be someone with social work, public health or community health education training. Regardless of who fills it, you should be sure to carefully define the role so it doesn’t cross the line from care coordination to care management.

Tom Ludwig, RN, MBA, FACMPE is an experienced clinic administrator and an accomplished author and speaker.  Visit Forward Healthcare Solutions.


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