Benefits of Care Coordination for Patients, Providers, and Healthcare Organizations

Without effective care coordination, this fragmented healthcare journey can quickly lead to:

• Duplicate tests
• Medication errors
• Missed follow-ups
• Poor communication
• Delayed interventions
• Increased readmissions
• Higher healthcare costs

As healthcare organizations continue transitioning toward value-based care, improving care coordination has become a strategic priority for hospitals, physician groups, Accountable Care Organizations (ACOs), Federally Qualified Health Centers (FQHCs), rural health clinics, and senior care organizations.

This guide explores the major benefits of care coordination, why care coordination is important, and how connected care technology supports scalable, integrated care coordination programs.

What is Care Coordination and Why It Matters

Care coordination is the intentional facilitation of care activities and information flow across all participating physicians to enhance care effectiveness and safety.

The right care coordination strategy depends on your clinical goals and the complexity of your patient population.

The key approaches include:

• Team-based care: It brings together a multidisciplinary team of primary care providers, nurses, care managers, and specialists. The team shares responsibility for the patient.
• Remote care coordination: It typically leverages telehealth and care coordination platforms to enable near-real-time oversight and proactive intervention.
• Care management programs: Examples include Chronic Care Management (CCM) and Transitional Care Management (TCM). They typically use a dedicated care manager or care team to establish clear accountability for a patient’s care.
• Accountable Care Organizations (ACOs): Apply when a group of providers shares accountability for a specific patient population to increase care quality and reduce the cost of care.

The need for provider collaboration is increasing due to a rising case-mix index.

Providers are seeing more patients, and these patients increasingly have more complex conditions. For instance, new data show that the case-mix index rose 5% over 5.5 years.

The increase in complexity means the average patient must see more primary care providers and specialists, who must now prioritize coordination. In fact, a study published in the Annals of Internal Medicine reports that the share of Medicare beneficiaries seeing 5 or more physicians per year rose from 19.1% to 35.1% over 10 years.

Therefore, effective care collaboration systems are necessary to ensure safe and high-quality care.

Common Care Coordination Models

The right care coordination strategy depends on your organization’s clinical goals, patient population, and operational structure.

Several care coordination models are commonly used across healthcare systems.

Team-Based Care

Team-based care coordination brings together multidisciplinary healthcare professionals who share responsibility for patient care.

These teams may include:

• Primary care physicians
• Specialists
• Nurses
• Care coordinators
• Social workers
• Pharmacists
• Behavioral health professionals

This model improves collaboration and creates greater continuity across the patient journey.

Remote Care Coordination

Remote care coordination leverages telehealth, connected devices, and care coordination technology to support patients outside traditional clinical settings.

This model enables:

• Continuous monitoring
• Early intervention
• Ongoing patient engagement
• Proactive chronic disease management
• Improved communication across care teams

Remote care coordination is especially valuable for senior care coordination and high-risk chronic disease populations.

Care Management Programs

Structured care coordination programs such as:

• Chronic Care Management (CCM)
• Transitional Care Management (TCM)
• Principal Care Management (PCM)
• Advanced Primary Care Management (APCM)

help organizations improve accountability and patient engagement through dedicated care management workflows.

These programs establish clear ownership over care coordination activities while supporting reimbursement opportunities under Medicare and value-based care arrangements.

Accountable Care Organizations (ACOs)

ACOs are provider networks that share financial accountability for improving quality outcomes while reducing total cost of care.

These organizations heavily rely on integrated care coordination to:

• Reduce readmissions
• Lower avoidable utilization
• Improve quality measures
• Enhance patient outcomes
• Support shared savings initiatives

Benefits of Care Coordination for Patients

As the primary goal of care coordination is to help you deliver care effectively, you can expect the following benefits for your patients:

• Improved patient safety: Coordination helps reduce medication errors and facilitates better transitions between care settings. Your patients benefit from better medication reconciliation, which ensures that a specialist won’t prescribe something that reacts poorly with other prescriptions.
• Better patient experience: With the average Medicare patient seeing 5+ physicians a year, the burden on patients can be high if they have to navigate the healthcare system alone. When you actively coordinate interactions, your patients feel more supported. Also, the interactions feel continuous across settings rather than being reset each time.
• Superior health outcomes: Good coordination has been shown to improve adherence and reduce ED utilization and readmissions. For instance, a multidisciplinary coordination program at Massachusetts General Hospital saw readmission rates drop from 21% to 14.5%.
• Increased Patient Engagement: Effective care coordination encourages patients to become more active participants in their own care journey. Ongoing communication, personalized coaching, and proactive outreach improve:
  • Adherence
  • Preventive care participation
  • Self-management behaviors
  • Follow-up compliance

Also, chronic disease management programs leveraging telehealth platforms for coordination are reporting significant reductions in ED utilization and readmission rates.

For instance, a pilot study evaluating the impact of a CCM team using telehealth visits for care coordination found that avoidable ED visits dropped from a mean of 6.83 to 3.0 per patient.

Based on our experience, achieving such outcomes requires more than refining your coordination protocols. It also demands infrastructure for proactive patient monitoring, real-time visibility, and seamless communication.

At KangarooHealth, we enable this as follows:

• We offer the largest library of FDA-cleared/approved connected devices to enable remote monitoring of your chronic patients’ physiological data.
• We have a robust cloud-based platform to aggregate the data, supporting CCM, Remote Patient Monitoring (RPM), Remote Therapeutic Monitoring (RTM), Principal Care Management (PCM), Advanced Primary Care Management (APCM), and Guiding an Improved Dementia Experience (GUIDE).
• Our platform has features to support continuity of care and coordination across providers.

Ready to see how we can help you improve care coordination?

Schedule your free demo to speak with an expert and explore what’s possible with remote patient care and seamless care coordination workflows.

Benefits of Care Coordination for Providers

While care coordination primarily serves your patients, it can also be a strategic advantage for you as a provider by helping improve clinical efficiency.

The improvements can help you in several ways, including:

• Reduced burnout: Care coordination reduces the time you spend searching for labs or discharge summaries. The consequence is a lower workload as you don’t have to provide duplicate services such as repeated tests.
• Better decision-making: Coordinated systems and software give you a unified view of the patient’s data. With a longitudinal view (including home-based data from Remote Patient Monitoring), you’ll be better equipped to make more accurate clinical decisions.
• More time for patient care: Streamlined care coordination workflows replace inefficient phone and fax systems with synchronized dashboards. The result is a reduced need for time-consuming manual follow-ups, freeing up time for actual patient care.

Benefits of Care Coordination for Healthcare Organizations

Under value-based care, healthcare organizations are using care coordination to help manage rising healthcare costs.

These efforts provide organizations with the following benefits:

Revenue Protection for Practices and Hospitals

Value-based care contracts incentivize healthcare organizations to achieve superior outcomes and lower costs through shared-savings opportunities.

For instance, under the Accountable Care Organization (ACO) model, healthcare providers are financially incentivized to coordinate care. If a group of healthcare providers delivers high-quality, coordinated care that keeps spending below the established benchmark, they can share in the cost savings they generate.

This approach creatively turns care coordination into a tool for your healthcare organization to drive revenue.

Lower Healthcare Costs for Payors

As we’ve discussed, key benefits of better care coordination include lower readmissions and reduced avoidable ED utilization.

These events are major cost drivers in the healthcare system, so reducing them can significantly reduce costs for payors. For instance, one study recorded a 44% reduction in 30-day readmissions and a 38% reduction at 90 days. These reductions translated into 11% cost savings for the payor.

Reduced Readmissions and Utilization

One of the most important benefits of care coordination is reducing avoidable utilization.

Strong transitional care coordination and chronic disease management programs can significantly lower:

• 30-day readmissions
• Emergency department visits
• Inpatient admissions
• Disease exacerbations

Reducing avoidable utilization helps organizations improve quality performance while lowering overall healthcare costs.

Improved Value-Based Care Performance

Care coordination is foundational to success under value-based care arrangements.

Organizations participating in:

• ACOs
• Medicare Shared Savings Programs
• Risk-based contracts
• Population health initiatives

must effectively coordinate care to achieve quality benchmarks and cost targets.

Improved coordination supports:

• Better HEDIS performance
• Enhanced quality reporting
• Shared savings opportunities
• Risk adjustment optimization
• Population health management

What an Effective Care Coordination Model Looks Like

With the benefits of care coordination now apparent, how do you build a coordination strategy that ensures your patients are supported across every stage of the care journey?

Here are some of the key components of an effective care coordination model:

Connected Data Infrastructure

You want every setting your patient goes to to have real-time access to their unified data. In practice, this looks as follows:

• A specialist can instantly access a primary care physician’s notes.
• Lab results are immediately recorded into the patient record.
• Discharge summaries are instantly shared with outpatient providers.

For this to happen, you need a connected infrastructure that enables seamless data flow between different EHRs. It is usually supported by interoperability standards like HL7 FHIR.

Proactive Patient Monitoring

For high-risk chronic populations, it is best to integrate remote monitoring into care coordination programs. For instance, you can offer both CCM and RPM services to proactively monitor your chronic patients with comorbidities.

In practice, this is how it may look:

• Your care team identifies high-risk patients who qualify for RPM and CCM.
• You get consent and enroll the patients into the programs with defined thresholds and escalation protocols.
• Your team reviews the incoming data and checks in regularly.
• The incoming data provides near-real-time insights that help you detect early warning signs and intervene proactively before conditions worsen.

Clearly Defined Coordination Workflows

To ensure care coordination activities don’t break down, you must assign clear ownership to each activity. Your workflows should clearly state when something should be done, who does it, and how.

In practice, this means that each activity has a “trigger” and an “owner”. Here’s what it may look like:

• Post-discharge follow-up: After discharge, your system automatically assigns a nurse or care coordinator to contact the patient within 48 hours.
• Referral management: Your care coordinator tracks whether a specialist visit was scheduled/completed.
• Care gap outreach: Where check-ins or screenings are overdue, a staff member is assigned to reach out to the patient.

How KangarooHealth Helps Strengthen Care Coordination in Your Organization

Designing an effective care coordination model is only half the battle. The other half is to ensure it can work consistently and reliably within your organization by using a platform that standardizes workflows and enables collaboration across care teams.

Here’s how our platform can help you strengthen care coordination:

• We offer customized implementations: KangarooHealth offers personalized implementations that include custom EHR integrations. Also, we provide white-label clinical monitoring that can be branded and customized according to your existing clinical workflows.
• We help standardize care protocols: Ad hoc protocols are unscalable and difficult for the collaborating physicians to interpret. It is best to create “care pathways” for the conditions you manage. KangarooHealth supports 50+ chronic conditions with customizable care pathways, allowing you to adjust care protocols to fit your patient population and clinical goals.
• We offer patient-centered training: Care coordination works best when patients are active participants in the coordination plan. We provide staff and patient training to ensure the success of the programs and to enhance patient engagement and adherence.

Ready to strengthen collaboration in your healthcare organization with our all-in-one connected care platform?

Book a demo to see how KangarooHealth supports quick adoption of care coordination in chronic care.

Frequently Asked Questions (FAQs)

Let’s now answer some common questions about care coordination:

What is the Cost of Care Coordination Programs?

There isn’t a set price. The cost will depend on your coordination model and your implementation partner.

Because Medicare reimburses for qualifying coordination activities, many coordination programs are revenue-positive. Further, you can eliminate cost as a barrier to entry by working with KangarooHealth, which offers zero setup costs.

What Tools Support Care Coordination at Scale?

You will likely find the following tools necessary for scaling your care coordination program:

• An Electronic Health Record
• An interoperability layer (e.g., Epic Care Everywhere)
• A care management or remote patient care platform
• RPM devices for remote monitoring
• Population health platforms

What is the ROI of Care Coordination For Hospitals?

The ROI of care coordination for hospitals mainly comes from preventing avoidable readmissions and reducing costly ED utilization. Other cost savings come from preventing duplicate services, such as duplicate tests.

It’s noteworthy that reducing readmissions and ED utilization frees up beds and other resources, enabling greater throughput. You can serve more patients without expanding physical infrastructure.

What Is the Future of Care Coordination?

The future of care coordination will increasingly involve:

• AI-driven workflows
• Predictive analytics
• Real-time interoperability
• Connected care platforms
• Automation
• Whole-person care coordination
• Continuous remote monitoring

Healthcare organizations are steadily moving toward proactive, data-driven, longitudinal care coordination models.

Conclusion

Care coordination benefits your healthcare organization by improving patient outcomes, lowering care delivery costs, and enhancing the patient experience.

These benefits are key goals of value-based care models. Nonetheless, achieving these objectives requires more than just a good care coordination strategy. You need a care coordination platform built with value-based care in mind, along with the right devices and workflows.

This is where KangarooHealth comes in. Our connected care platform enables remote patient care and care coordination for 50+ chronic conditions with customizable care pathways. Further, we automate documentation capture for all care coordination activities, ensuring accurate and timely reimbursements.

Contact us today to see how our platform, devices, and customizable workflows support care coordination in chronic care.