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Care Coordination

The Agency for Healthcare Research and Quality defines care coordination as a service that:

“Involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care. This means that the patient's needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient.”¬†

Care coordination can be a useful strategy to improve the health and wellness of people with disabilities. Creating an organized care plan can reduce medical errors, coordinate appointments across different care requirements, and reduce duplication of services. People with disabilities often have complicated medical needs that require appointments with multiple providers. A care coordinator can work with the patient to make their experiences with the medical system more efficient and effective.

Coordination services can be provided by clinical or non-clinical providers. Types of care coordinators identified in the Rural Care Coordination Toolkit include:

  • Health Educators
  • Patient Navigators
  • Care Managers
  • Community Health Workers
  • Registered Nurses

Coordinators can also connect rural citizens with disabilities to a number of services outside of the hospital or clinic setting, including medical equipment, home healthcare, Medicaid and medical reimbursement, and homemaker and meal delivery services.

Program Clearinghouse Examples

Resources to Learn More

Cancer Patient Navigation Program Toolkit
A toolkit to help health professionals implement a program that provides individualized support, case coordination, and targeted services, with a specific focus on cancer care.
Organization(s): Kansas Cancer Partnership
Date: 9/2009

Care Coordination Topic Guide
The care coordination topic guide defines and discusses care coordination in a rural setting in more detail, as well as provides different ideas to implement care coordination in a rural community.
Organization(s): Rural Health Information Hub

IMPACT model
This is an evidence-based program that uses care coordination to work with clients that have depression and a diagnosis of chronic disease or other major health condition. The treatment approach uses multiple, collaborating providers that take their clients on a step-based approach to improving their health status.
Organization(s): Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services

Key Takeaways for Launching Care-Coordination Program
This website provides a case study of a care coordination program for children with disabilities in central and southeastern Ohio. Using lessons learned from the development of an accountable care organization's pediatric care-coordination effort, key takeaways are presented to assist other organizations looking to start a care coordination program.
Organization(s): Partners for Kids

Outreach Workers Connect Low-Income Individuals Living in Rural Areas to Home- and Community-Based Services, Reducing Costs and Nursing Home Placements
This evidence-based program, from the Tri-County Rural Health Network, uses community connectors to help arrange services for rural residents. The program description includes the steps taken for implementation as well as details about the program that can be used in other settings.
Organization(s): Agency for Healthcare Research and Quality
Date: 2004