Care Coordination

Quality clinical care and patient safety requires the effective exchange of health data between patients’ providers across multiple care settings. It involves a detailed knowledge of the information exchange options in the population area served by your facility. Creating a great care coordination plan requires the right mix of people, process and technologies working in tandem to achieve your scope and objectives.

Need more information on Care Coordination resources or how to get involved with the community? Connect with Adam Bazer on Twitter @AdamBazer or LinkedIn.

Identify your Organization’s Health Interoperability Ecosystem

Your organization’s health interoperability ecosystem is comprised of the individuals, systems and processes that want to share, exchange and access all forms of health information, including discrete, narrative and multimedia. Individuals, patients, providers, hospitals/health systems, researchers, payors, suppliers and systems are all potential stakeholders within this ecosystem. Each is involved in the creation, exchange and use of health information and/or data.

An efficient health interoperability ecosystem provides an information infrastructure that uses technical standards, policies and protocols to enable seamless and secure capture, discovery, exchange and utilization of health information. Learn more about health interoperability ecosystems.


  • Identify internal & external stakeholders who must be involved in the evaluation, implementation, and maintenance of your organization’s health interoperability ecosystem and identify internal resources devoted to those actions
  • Assess your organization’s gaps in its ability to share, exchange and access all forms of health information across its health interoperability ecosystem
  • Create action plans to resolve health interoperability ecosystem gaps
  • Act on action plan’s recommendations to resolve a specific health interoperability ecosystem gaps
  • Analyze results of actions on closing health interoperability ecosystem gaps


HIMSS HIE Toolkits: Find the tools you need to understand health information exchange in all healthcare settings. Ambulatory, Enterprise, and Public Health HIE Toolkits provide comprehensive fact sheets, analyses, checklists, white papers and other resources to help guide and inform professionals involved with HIE at all levels.


PCHA Thought Leadership: The Fundamentals of Data Exchange- The purpose of this white paper is to provide a basic description of the data that is being exchanged between sensors, gateways, and end services and value-add the Continua Design Guidelines provide beyond the referenced standards to make implementations truly interoperable.

Analyze Gaps in current Care Coordination Workflow Touchpoints & Processes

Planning for effective care coordination means gaining an understanding of all of the care transfer moments within your patients’ clinical workflow across the care settings they interact with. A workflow analysis entails reviewing all processes in an organization with a view toward identifying inefficiencies and recommending improvements. The work begins with establishing desired results from the analysis with an organizations leadership.


  • Evaluate historical and ongoing initiatives around care coordination internally and externally
  • Identify the patients as well as the disease entities that need more care coordination and consider establishing a disease specific registry
  • Identify the categories of exchange of information that you are trying to target and educate clinicians about them, including results from transfer of patients, facilitated transfers, direct, medication orders, etc.
  • Formulate other informational needs from evaluations and patient needs

HIMSS Toolkit: Workflow Redesign in Support of the Use of Information Technology Within Healthcare

This toolkit provides guidance and best practices that will help enable provider organizations to successfully approach a workflow redesign initiative. Learn More#9

Devise Actions Your Practice Can Take To Resolve Care Coordination Gaps

Care coordination happens one patient at a time. Effective care coordination requires care team members and those who support them to first integrate evidence-based care coordination best practices into their clinical workflow and then act on them when patients transfer from one care setting to another.


  • Design a plan and success metrics to ensure that the physicians have the tools needed to manage care through coordinated efforts.
  • Acknowledge and address mismatching clinical expectations and technical expectations.
  • Engage internal and external stakeholders to identify opportunities to improve care through data analysis.
  • Engage all clinical stakeholders in care coordination at the point of transfer
  • Add care coordination review as part of post-visit care management analysis

HIMSS17 Education: It’s Not Always About Technology: Effective Coordinated Care: This presentation focuses on Martin Luther King, Jr. Community Hospital and the integrated care plan followed since 2015. MLKCH’s CIO Sajid Ahmed explains how his community hospital employs a variety of strategies, such as eConsults, telehealth services, information sharing, mobile technologies and partnerships to offer patients expanded and easier access to care services. Learn More.

Assess Effectiveness of Care Coordination Gap Analysis Action Plan Results on Key Care Coordination Metrics

Once actions have been taken in light of the care coordination gap analysis, it is important to review the results of those actions as they relate to key care coordination metrics, such as those described in AHRQ’s Care Coordination Measures Database.


  • Assess results of care coordination gap analysis action plans
  • Identify care coordination gap analysis action plans that did not result in effective impact on care coordination activities
  • Formulate new action plan to resolve the care coordination issue
  • Begin care coordination improvement actions based on the newly formulated action plan

AHRQ’s Care Coordination Measures Database: This database is intended to assist evaluators and researchers interested in care coordination measurement. Users of the database can compare more than 60 validated care coordination measurements tools found in the Database, many of which are intended for ambulatory care settings to identify those that are most appropriate for their needs.