What Is Coordinated Care?

Coordinated Care is the meticulous organization of patient care activities between two or more participants (including the patient) that are involved in a patient’s care, used to simplify the appropriate delivery of health care services. Organizing a patient’s care involves the directing of personnel and other resources needed to carry out all required patient care activities, and is often managed by information being communicated to everyone that is involved within the patient’s care.

Why Is Coordinated Care Important?

Coordinating care is a strategy that can improve the effectiveness, safety, and the efficiency of healthcare. Targeted and well-designed coordinated care that is delivered to the right people can improve outcomes for everyone.

The main goal of care coordination is to meet the patient’s needs and preferences while delivering  high-quality, valued health care. This means that the patient’s needs and preferences are known and communicated to the providers treating them, and this information is then used to guide the delivery of safe, appropriate, and effective care.

Specific activities used to achieve coordinated care include:

  • Establishing accountability and agreeing on responsibility
  • Communicating and sharing knowledge
  • Helping with transitions of care
  • Assessing patient needs and goals
  • Creating a proactive care plan
  • Monitoring and follow up, including responding to changes in the patient’s needs
  • Supporting the patient’s self-management goals
  • Linking to community resources
  • Working to align resources with patient and population needs

Why Is Coordinated Care Needed?

There are two main reasons why care coordination is necessary; the first being that a lack of coordination can be unsafe, or even fatal for patients. When abnormal test results are not communicated correctly between a patient’s providers or between providers and their patients, or when prescriptions are issued by multiple physicians and there is a lack of awareness of the medications the patient is already taking, the risk for poor patient outcomes is high.

The second reason is that uncoordinated care is more costly for patients and the healthcare system itself. Lack of coordinated care can increase duplicate services and tests, increase the risk of preventable hospital admissions and readmissions, and also adds to the overuse of more intensive procedure.

Damien Neuman
October 1, 2018


What is a Clinical Care Team?

The definition of a clinical care team is:

A clinical care team for a given patient consists of the health professionals—physicians, advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, and other healthcare professionals—with the training and skills needed to provide high-quality, coordinated care specific to the patient’s clinical needs and circumstances.

This team-based model requires a new way of thinking about clinical responsibilities and leadership, one that recognizes that different clinicians will assume principal responsibilities for specific elements of a patient’s care as the patient’s needs change; and while the team as a whole must ensure that all elements of care are coordinated for the patient’s benefit.

Who are these Health Professionals?

Clinical care teams usually include groups of physicians, nurses, physician assistants, clinical pharmacists, social workers, and other health professionals that help to establish new lines of collaboration, communication, and cooperation to better serve their patient’s needs.

Some of these team members are doctors or technicians who will help diagnose disease; others are experts who treat diseases or care for a patient’s physical and emotional needs. These health professional might be:

  • Doctors
  • Physician Assistants
  • Nurses
  • Pharmacists
  • Dentists
  • Technologists and technicians
  • Therapists and rehabilitation specialists
  • Emotional and social support providers
  • Administrative and support staff
  • Community health workers and patient navigators

Here we will give a brief introduction to these different types of health care professionals on the care team.


Doctors, or physicians, are key members of the healthcare team. They have years of education and training. They may be primary care doctors who focus on preventive health care, or specialists who diagnose and treat conditions that require a specific area of knowledge.

Physician Assistants (PA’s)

Physician’s Assistants are licensed to practice medicine but are supervised by a doctor. They work alongside physicians to perform physical examinations, diagnose and treat illnesses, order and interpret diagnostic tests, prescribe medication, and assist in surgery.


Nurses work closely with patients but their duties depend on their education, their area of specialty and work setting. There are three different types of nurses, Licensed Practical Nurses (LPN), Registered Nurses (RN’s), and Nurse Practitioners. Each of these differ because of their length and type of education.


Pharmacists are experts in the field of medication. They work with physicians or physician assistants to ensure new prescriptions do not interact with a patient’s current medications, that the right dosage for a particular medication has been prescribed, and to answer any questions that the patient may have about their prescribed medication.


Dentists diagnose and treat problems related to the teeth and mouth, along with giving advice and administering care to help prevent future problems. They instruct patients about the importance of brushing, flossing, fluoride, and other aspects of dental care.


Technologists and technicians have a more technical role in diagnosing or treating disease. Lab Technologists help providers diagnose and treat disease by analyzing body fluids and cells. Radiology Technologists help providers diagnose and treat disease by taking x-rays. Pharmacy Technicians help pharmacists prepare prescription medications but do not need any type of degree or certification.

Therapists and Rehabilitation Specialists

Therapists and rehabilitation specialists help people recover from physical changes caused by medical conditions, chronic diseases or injuries. Types of rehabilitation specialists include physical therapists, occupational therapists and speech therapists. Occupational therapists help patients perform tasks needed for every-day living or working and usually have patients who have physical, mental or developmental disabilities. Physical therapists work with patients when they have an injury, disability or medical condition that limits their ability to move or function. Respiratory therapists treat and care for patients with breathing problems like asthma or emphysema. Speech therapists work with patients who have problems related to speech, communication or swallowing. Lastly, recreation therapists provide a wide range of interventions and therapy that is designed to improve a patient’s functioning and keep them as healthy, active and independent as possible.

Emotional and Social Support

There are many healthcare team members who provide emotional and social support rather than physical support. These healthcare members are called mental health professionals, who help patients with the emotional aspect of living with a chronic disease. Psychiatrists are medical doctors who diagnose and treat mental, emotional and behavioral disorders. Psychologists deal with mental processes, especially when patients are stressed, but they are not medical doctors; instead they have a Doctor of Psychology (PsyD) or a doctor of philosophy degree (PhD).

Social workers that work in a clinical or hospital setting will help patients and families cope with the emotional, physical and financial issues related to having an illness. Depending on a patient’s needs a social worker may help coordinate services like housing, transportation, financial assistance, meals, long-term care, or hospice care.

Administrative and Clerical Staff

Administrative and clerical staff coordinate and facilitate patient care. They schedule appointments, answer phones, greet patients, keep medical records, handle medical billing, fill out insurance forms, arrange for laboratory or other diagnostic services, and handle financial records. These duties help to keep things running smoothly in a hospital or doctors office.

Community Health Workers and Patient Navigators

Community health workers link patients to primary care providers, health information, health screening, financial assistance or transportation. Patient navigators work with patients to minimize the barriers that keep them from getting healthcare. These barriers could be related to low income, transportation, childcare, language or ability to read forms or to understand the healthcare system.

Each of these care team members play an important role in coordinating and delivering care, and supporting each patient based on their needs.

Tyler Comstock
October 1, 2018


How can virtual groups be beneficial?

With the goal of virtual groups being “to clinically benefit patients and to encourage collaboration”, the concept of virtual groups is still being fully defined by CMS. Ideally, virtual groups would allow individual physicians and small practices the ability to connect and pool together their resources when it comes to quality reporting and improvement. This provision would benefit the independent clinicians attempting to operate with the difficulties of reimbursement reform without taking away their independence.

Elation Health believes that virtual groups can and should be a powerful tool to not only create administrative efficiencies for the providers who participate, but also to encourage collaboration that improves the quality of a patient’s health care.

So far, this is what CMS has said about virtual group reporting within the Quality Payment Program, “Flexibilities and Support for Small Practices” PDF:

“Under MIPS, clinicians will have the option to be assessed as a group
across all four MIPS performance categories. The law provides that solo and small
practices may join “virtual groups” and combine their MIPS reporting. CMS is seeking
public comment on how virtual groups should be constructed, and anticipate being able
to implement virtual groups in the second year of the program. CMS wants to make sure
the virtual group technology is meaningful and simple to use for physicians.”

Elation Health believes independent provider-led initiatives like virtual groups should be at the focus of CMS’ strategy for implementing MACRA.

Additionally, because we are so excited for the addition of virtual groups into the MACRA Final Rule, we have provided feedback on the concept of virtual groups to CMS. In our comment we detailed specific suggestions for how CMS should implement these groups, including the metrics which should be utilized to demonstrate the effectiveness of virtual groups and their impact on care quality and health outcomes.

To learn more about how Elation is supporting independent physicians, read the full text of our comment here.

Greg Miller
October 1, 2018


Frequently asked questions about primary care physicians

What is a Primary Care Physician?

A Primary Care Physician is considered a patient’s main doctor and is responsible for dealing with the majority of their health care needs and/or concerns relating to their general health. If their patient has a problem that is more complex than the PCP can manage they will refer them to see a specialist in the area of the health issue.

What health care needs do PCPs manage?

Primary Care Physicians give their patients yearly physical exams and conduct preventative health care; they also inform their patients on what future health care problems they are at risk for developing based on family medical history. They also provide patients with information on how they can prevent or decrease risk for those medical problems.

PCPs will also take care of any non-emergency problems their patients may have, like a cold that has gotten worse over time or pink eye, they can fix you up with some medication and remedies for feeling better. They will also manage and monitor and chronic health issues their patients may have like high blood pressure or acid reflux disease.

What is the importance of the PCP role?

The most valuable role Primary Care Physicians have is their ability to coordinate care. If a patient has complicated medical problems, needs multiple specialist physicians, and is in and out of the hospital they will need to have good care coordination.

PCPs knows what each of the specialists are doing and makes sure they’re not duplicating tests or procedures that have already been done by another specialist. PCPs also make sure all of a patient’s prescriptions are absolutely necessary and all are compatible with each other. Care coordination is such a large part of a patient’s health care but isn’t given that much thought by the general public.

Is the time spent with patients and quality of care being received satisfactory?

Due to the fact that most doctors only make money by prescribing, testing, scanning, and seeing as many patients as they can, they do not get to spend quality time with their patients to understand their health care problems. This is dangerous in the case of unnecessary testing and prescribing, and it is also dangerous because the lack of communication in the doctor-patient relationship impacts the quality of care. Sadly, this is the works of the American health care system, not the physicians.

Greg Miller
September 24, 2018


Value based care and population health management

The Centers for Medicare & Medicaid Services (CMS) continues to emphasize the need for independent physicians to provide quality care that is reimbursed not on the basis of the quantity of patient visits but on the quality of patient outcomes. Many commercial insurance companies are following suit, emphasizing reimbursement for value-based care over individual visits.

A recent article published by the Healthcare Information and Management Systems Society (HIMSS) noted that “Population health management has been widely discussed as the solution to help healthcare organizations reach value-based care goals.” Additionally, the article states that “there are three keys to a successful program: data analytics, technology adoption and the inclusion of the patient as a partner.”

Population health management involves tracking data on individual patients within a population group. Healthcare IT News reports that the “concept of population health first came about in 2003 when David Kindig and Greg Stoddart defined it as ‘the health outcome of a group of individuals, including the distribution of such outcomes within the group.’”

The ability to manage data regarding the population can be a significant factor in the value-based care provided to those patients. HIMSS emphasizes that “real-time data enables clinical decision support which can help payers and providers address at-risk populations, and provide timelier interventions. Analytics help us find gaps in care and determine whether healthy outcomes were achieved.”

An electronic health record (EHR) solution enables the independent physician to holistically evaluate the patient population with a longitudinal record that trends vitals and lab values over time. Partnering with the patient to manage healthcare plans and medications improves the value of the care provided to that patient. In fact, most patients want to be more actively involved in decisions that affect their ongoing health.

Quality technology, data analytics, and patient involvement enable the independent physician to manage the population’s health to produce quality patient outcomes and to more successfully participate in value-based care.

Greg Miller
September 18, 2018


What are value-based care programs?

The move toward value-based care began in 2008 with the passage of the Medicare Improvements for Patients & Providers Act (MIPPA). Ten years later, in 2018, there are a number of value-based programs designed to reward healthcare providers for the quality of their care rather than the number of patient visits.

The Centers for Medicare & Medicaid Services (CMS) states that its value-based programs support their three-part aim of:

  • Better care for individuals
  • Better health for populations
  • Lower cost

The five original value-based programs had as their goal the linking of provider performance of quality measures to provider payment:

  • End-Stage Renal Disease Quality Incentive Program (ESRD QIP)
  • Hospital Value-Based Purchasing (HVBP) Program
  • Hospital Readmission Reduction (HRR) Program
  • Value Modifier (VM) Program (also called the Physician Value-Based Modifier or PVBM)
  • Hospital Acquired Conditions (HAC) Reduction Program

In further promoting the goal of providing quality care to patients, increasing the focus on value-based care over the frequency of patient visits, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) created a Quality Payment Program (QPP). The QPP:

  • Changes the way that Medicare rewards clinicians for value over volume
  • Streamlines multiple quality programs under the new Merit Based Incentive Payments System (MIPS)
  • Gives bonus payments for participation in eligible alternative payment models (APMs)

CMS states that their value-based programs are important because they encourage a move toward paying providers based on the quality, rather than the quantity of care they give patients. Fewer hospital readmissions, coordinated care between healthcare providers, and reduced costs for patients and providers are some of the anticipated results of the value-based care programs.

Electronic health records (EHRs) are also an essential element in value-based care programs. Providers who take advantage of the many features of an EHR system, including accessing patient information immediately, coordinating with a patient’s specialty providers, and communicating with patients securely are better equipped to provide the quality care that is the ultimate goal of value-based care.

Damien Neuman
September 10, 2018


Exploring chronic care management adoption for primary care physicians

As the population in the US ages, more patients will need care for chronic conditions. Those over the age of 65, a group that is increasing in numbers as Baby Boomers enter the age of retirement and Medicare eligibility, are more prone to conditions such as arthritis, hypertension, diabetes, and other chronic conditions that will require management by primary care physicians.

A recent survey conducted by Quest Diagnostics explored the adoption of chronic care management. The survey, involving 801 primary care physicians and patients over 65 with multiple chronic conditions, found that primary care physicians feel “overwhelmed and overworked.” These physicians want to spend more time with the patients who need them most but feel their lack of time impedes the quality of that care.

Specifically, the survey found that “almost nine in ten PCPs (86%) say they have felt unable to address the needs of their chronic care patients adequately, with almost three in ten (28%) saying this happens a lot. For most physicians—85 percent—lack of time is the key culprit.”

Although most (95%) of the physicians participating in the survey said they are in primary care because of a desire to care for the “whole patient,” two-thirds (66%) of them say they “don’t have time to address social and behavioral issues, such as loneliness or financial concerns, that could affect the health of their patients,” possibly contributing to or exacerbating chronic conditions among those patients. Only 9% of the physicians participating in the survey are “very satisfied that their patients are getting all the attention they need to care for all medical issues.

Patients with chronic conditions also typically require continued medication and, in fact, account for 83.1 percent of all prescriptions in the United States. The surveyed physicians indicated they felt the need to follow up with these patients to ensure they understand their instructions fully, with 88% saying they are “concerned their Medicare patients with multiple chronic conditions are not taking their medications as prescribed.”

An additional challenge for primary care physicians treating patients with chronic health conditions is the Medicare reimbursement schedule. Most of the physicians surveyed stated they need to see these patients multiple times throughout the year, to properly manage their conditions; however, under Medicare, patients are eligible for an introductory preventive visit within 12 months of qualifying for Medicare and an Annual Wellness Exam every year thereafter.

Greg Miller
August 8, 2018


How primary care can contribute to population health

The primary care physician often acts as a home base for patients who need additional or specialty care. Patients with chronic or complex conditions, especially, tend to see multiple providers for care that needs to be coordinated by the primary care physician. Contributing to population health is a main goal for coordinating this care.

A framework recently developed by the Public Health Leadership Forum (PHLF) and Healthcare Transformation Task Force (HCTTF) emphasizes the need for cross-coordination among independent physicians and other health providers, including social workers, whose focus is also on population health.

As HCTTF notes, “There is mounting recognition that to truly improve health outcomes in the U.S. and curb chronic diseases there must be an interdisciplinary, coordinated, and cross-sector approach to address acute conditions and the upstream social factors that contribute to poor health outcomes.”

HCTTF further explains that the framework “requires action from key stakeholders to realize the comprehensive community wellness vision:

  • Public health and health care leaders can use the framework to convene collaborative groups, commit the time and resources needed to effectively collaborate on a shared vision, and grow a generation of health professionals who view multi-sector collaboration as the norm.
  • Local, state, and federal policy makers can learn from the examples of effective cross-sector collaboration that informed development of the framework to advance policies and programs that create the catalysts and conditions in which collaborative wellness approaches thrive.
  • Health practitioners can identify opportunities to engage and support community-based organizations in structured partnerships to ensure health interventions can truly take hold.”

Primary care providers can take advantage of technology when caring for their patients, with an eye toward population health management. Elation’s Clinical First Electronic Health Record (EHR) enables primary care providers to effectively coordinate care while:

Tyler Comstock
July 30, 2018


Survey says patients want better care coordination, communication

Communication with a patient can make a significant difference in healthcare outcomes for both the patient and the independent physician. Likewise, with an aging population, effective collaboration with specialty providers and healthcare facilities can become a crucial factor in the treatment of patients with chronic or complex conditions. As the transition to value-cased care continues, communication and coordination of services will become increasingly important.

Those two areas are also of vital importance to the patients themselves, a recent survey discovered. Inaugural Health Ambitions Study, a research project conducted by Aetna, posed a variety of questions to 1,000 people as well as separate questions to 400 physicians, divided evenly between primary care and specialty providers. The survey found that the majority of patients want their physicians to communicate with them better and to coordinate their care more effectively.

The survey found that “77% of respondents said it’s very important for their doctors to talk in an easy-to-understand manner.” Taking the time to explain diagnoses, medications, and treatment plans can make a difference in whether patients understand their medical situation and take their medications properly. Follow-up self-care by the patient can also be impacted by whether the physician made the instructions clear and understandable during the visit.

Communication after the visit can also contribute to positive outcomes. Patients surveyed also believe that “privacy and data security are important parts of healthcare.” Communicating with patients electronically can ensure that all of their data is private and secure. Younger patients, in particular, prefer digital tools when accessing their medical records and communicating with their physician.

Of those patients participating in the Aetna survey, just over half want their independent physicians to coordinate care with other healthcare providers more effectively. A tool such as a Collaborative Health Record will provide independent physicians the ability to communicate and coordinate with other healthcare providers to ensure their value-based care results in quality outcomes.

Greg Miller
July 24, 2018


What do primary care physicians think about eConsult systems?

Primary care physicians (PCPs) quite often consult with specialty providers or refer patients to other healthcare providers, particularly when their patients have chronic or complex conditions. A relatively new technology enabling the use of electronic consultations may help reduce the costs to patients when they need the care of such specialty providers. Electronic consultations (eConsults) are “non–face-to-face (F2F) consultations between a PCP and a specialist that utilize secure messaging to exchange information.”

A recent study published in The American Journal of Managed Care (AJMC) examined the use of eConsults among primary care physicians, to determine their effect on healthcare costs. The study also revealed the physicians’ attitudes toward the new technology. The study involved a “total of 369 Medicaid patients (who) were referred for cardiology consultations by primary care providers who were randomly assigned to use either eConsults or their usual face-to-face referral process.” All sites studied used an integrated electronic health record (EHR) system.

The results of the study suggested that “eConsults are associated with total cost savings to payers due principally to reductions in the cost of cardiac outpatient procedures.” However, the study also found that some primary care physicians were adverse to the use of such technology, for varied reasons.

A total of 36 primary care physicians participated in the study. Although a number of the physicians saw improvements in efficiencies, particularly in the reduced time involved in a consultation, some of the participating primary care physicians viewed eConsults as actually adding to their own workload. Some also felt that the wait time for an eConsult was longer than for a traditional face-to-face consultation. The use of eConsults, in most cases, reduced the amount of administrative work involved in coordinating visits, which may have staffing implications for the practice.

The researchers noted that the appeal of eConsults may be outweighed by “patient visit volume, staff support shortages, perceptions about compensation, the excessive burden of administrative and clerical tasks, and institutional culture” and so needs further study.

Greg Miller
June 29, 2018