How to Improve Care Coordination [Examples Included]

Effective clinical care coordination helps healthcare providers create a more connected patient experience while reducing avoidable hospitalizations, emergency department utilization, redundant testing, and administrative inefficiencies.

In this guide, we’ll explore:

• Why care coordination matters
• Common care coordination challenges
• Proven care coordination models
• Strategies to improve care coordination
• Real-world examples
• How technology and care coordination software support value-based care success

Why is Care Coordination Important?

Care coordination is important because it is essential to providing better care at a lower cost, a key goal of value-based care.

Specifically, it is one of the key strategies you must use to achieve the Triple Aim of enhancing health for individuals and populations. These three goals are: ensuring quality outcomes (population health), reducing per-capita healthcare costs, and improving the care experience.

Improved Patient Outcomes

One of the biggest benefits of clinical care coordination is improved patient outcomes.

When providers, specialists, care managers, nurses, and support staff communicate effectively, patients receive more consistent and proactive care. Effective coordination helps reduce:

• Medication errors
• Missed appointments
• Delayed treatments
• Duplicate testing
• Preventable complications
• Hospital readmissions

This is especially important for patients with chronic diseases such as hypertension, diabetes, COPD, CHF, and chronic kidney disease who require ongoing monitoring and support.

Lower Healthcare Costs

Improving care coordination can significantly reduce healthcare costs by preventing avoidable high-cost events.

Better coordination helps organizations intervene earlier before conditions escalate into:

• Emergency department visits
• Inpatient admissions
• Readmissions
• Disease progression
• Acute exacerbations

Strong transitional care coordination programs are particularly effective at reducing costly readmissions following hospital discharge.

Better Patient Experience

Fragmented healthcare often makes patients feel confused and unsupported.

On the other hand, coordinated care creates a more connected and personalized experience. Patients feel more confident when:

• Their providers communicate with each other
• Follow-ups are organized
• Care plans are clear
• Someone proactively checks in on them
• Questions are answered promptly

This is particularly important in senior care coordination, where patients often see multiple providers across different care settings.

Reduced Administrative Burden

Care coordination also improves operational efficiency for healthcare teams.

Instead of manually tracking referrals, lab results, discharge summaries, and patient follow-ups across disconnected systems, organizations can streamline workflows through interoperable technology and standardized communication protocols.

This reduces administrative burden and allows clinical teams to spend more time focusing on patient care.

Additionally, improving care coordination is important because it enhances your own experience by reducing the administrative burden. You’ll spend less time digging for information or doing redundant tasks, leaving you with more time for actual patient interactions.

Common Challenges in Care Coordination

While significant progress has been made to streamline care coordination through increased funding and infrastructure development, some challenges persist.

Here are some of the common challenges you should prepare for:

Interoperability Problems

In some cases, such as chronic disease management in primary care, you may need a specialized platform in addition to your existing EHR. If the platform doesn’t integrate with your EHR, it creates data silos that hamper care coordination. Ensure the technology you onboard can integrate seamlessly with your existing EHR.

Referral Loop Breakdowns

Care fragmentation frequently occurs when specialists fail to communicate updates back to the primary care provider.

Without closed-loop referral tracking, patients may:

• Miss specialist appointments
• Experience duplicated services
• Receive conflicting care plans
• Fall through gaps in care

Structured workflows and referral tracking systems are critical for improving transitional care coordination and long-term care management.

Staffing and Resource Constraints

Healthcare organizations continue to face staffing shortages and growing patient complexity.

Care managers and nurses are often expected to coordinate:

• Chronic care management
• Transitional care management
• Follow-ups
• Medication reconciliation
• Referrals
• Patient outreach
• Quality reporting

Without workflow automation and centralized coordination tools, these responsibilities can quickly overwhelm clinical staff.

Care Coordination Models

To address most challenges that hamper effective care coordination, consider working within structured care coordination models. These models are deliberately designed to help you track patients across every touchpoint in the healthcare continuum.

Here are some of the frameworks that may align with your clinical goals and patient demographics:

Virtual Care Management (VCM)

VCM is a model that uses technology to monitor and engage patients outside of traditional care settings. It can help you engage patients living in remote areas and those with chronic conditions that require continuous oversight.

Medicare already runs reimbursable programs that benefit from technology-enabled remote care, and they include:

• Remote Patient Monitoring (RPM)
• Remote Therapeutic Monitoring (RTM)
• Chronic Care Management (CCM)
• Principal Care Management (PCM)
• Advanced Primary Care Management (APCM)
• Guiding an Improved Dementia Experience (GUIDE)

VCM enables better care coordination in the following ways:

• Remote monitoring of vitals with connected devices serves as an early-warning system, enabling you to intervene before symptoms escalate.
• A cloud-based platform serves as the central database where you can share information/data with other providers to coordinate care effectively.
• CMS financial incentives allow you to be reimbursed for qualifying services, creating a sustainable revenue stream to fund care coordination activities.

You don’t need to build your own platform or invest heavily in connected devices to implement VCM. At KangarooHealth, we’ve eliminated the barrier to entry by offering a turnkey implementation with zero upfront costs for platforms and connected devices.

Here’s why you should choose KangarooHealth:

• We support RPM, RTM, CCM, PCM, APCM, and GUIDE.
• Our platform supports 50+ chronic conditions with customizable care pathways.
  We have the largest library of FDA-cleared/approved devices.
• We have a dedicated virtual team of US-based nurses, so you can implement VCM without hiring new staff.

Why Organizations Choose KangarooHealth

At KangarooHealth, we help healthcare organizations improve care coordination through scalable connected care infrastructure.

Our platform supports:

• RPM
• RTM
• CCM
• PCM
• APCM
• GUIDE

Additional capabilities include:

• Custom EHR integrations
• Population health software integrations
• Utilization management software integrations
• AI-driven risk stratification
• Quality measure reporting support
• 50+ customizable chronic condition pathways
• FDA-cleared connected devices
• US-based virtual nurse monitoring teams

We also provide turnkey implementation with no upfront platform or device costs, helping organizations launch programs quickly without major operational disruption.

Contact us today to speak with an expert and see how our remote care solutions can help you improve care coordination.

Patient-Centered Medical Home (PCMH)

The model aims to transform primary care into a cohesive system. The “medical home” in this case is a hub where a primary care provider and a multi-disciplinary team coordinate a patient’s needs.

The Agency for Healthcare Research and Quality (AHRQ) assigns the following 5 attributes to the model:

• Comprehensive care to meet a large majority of the patient’s healthcare needs
• Patient-centered care that’s oriented towards providing “whole-person” care
• Coordinated care to manage care across the entire healthcare system
• Quality and safety to ensure interventions are evidence-based
• Accessible services to reduce wait times

The model centralizes responsibility for care coordination, with the primary care provider serving as the hub or medical home.

Accountable Care Organizations (ACOs)

Accountable Care Organizations align providers under shared financial and quality incentives.
ACOs encourage collaboration between:

• Primary care providers
• Specialists
• Hospitals
• Post-acute care providers
• Care management teams

Organizations participating in ACO models benefit financially when they improve quality outcomes while reducing the total cost of care.

Because of their emphasis on utilization reduction and quality metrics, ACOs heavily rely on strong care coordination programs and interoperable technology.

Transitional Care Management (TCM)

Transitional Care Management focuses on patients during the critical 30-day period following hospital discharge.

The goal is to reduce:

• Readmissions
• Medication errors
• Care gaps
• Post-discharge complications

CMS requires several components for TCM reimbursement, including:

• Patient contact within 2 business days
• Medication reconciliation
• Follow-up visits
• Ongoing care coordination

Effective transitional care coordination is one of the most impactful ways to reduce avoidable utilization and improve patient outcomes.

How to Improve Care Coordination

Implementing the above care coordination models requires you to adopt a structured communication system and integrate interoperable technology.

Here’s how to do both to improve care coordination:

Implementation of Interoperable Technology

Most of the coordination failures you’ll encounter come from fragmented data. Interoperable technology solves data fragmentation by:

• Aggregating patient data into one unified view
• Connecting systems through Health Information Exchanges (HIEs) and APIs

You can leverage such integrations to assign tasks, securely message other providers, share care plans, and track your patients through the healthcare system.

Patient tracking also extends to the actions that have been taken. For instance, you can track whether care gaps have been closed, whether follow-ups have been confirmed/scheduled, and whether a referral has been received and completed.

Adoption of Structured Communication Workflows

To effectively use interoperable technology, you must employ standardized, repeatable frameworks to prevent communication failures.

Specifically, your communication workflows should include the following:

Clear Communication Triggers

Define specific events that trigger outreach or escalation, such as:

• Hospital discharge
• Abnormal vital readings
• Missed appointments
• Referral placement
• Medication adherence concerns

Assigned Accountability

Every coordination task should have a clearly assigned owner.

This improves accountability while reducing alert fatigue and communication breakdowns.

Closed-Loop Confirmation

Organizations should verify that referrals, follow-ups, and interventions are actually completed.

Closed-loop communication significantly reduces gaps in care.

Part of getting the above right is to reduce variability across your care teams. To make coordination predictable and scalable, ensure everyone follows the same protocol.

Effective Care Coordination Examples

The care coordination models we’ve discussed have already been implemented in different care settings with incredible success.

Here are some examples with their impact:

• The impact of virtual care: Geisinger Health Plan (GHP) implemented a telemonitoring program targeting patients with heart failure. In the sample enrolled in the telemonitoring group, the odds of 30-day and 90-day readmissions were 44% and 38% lower, respectively.
• The impact of closing the loop: A study examined the effectiveness of the closed-loop multidisciplinary approach at reducing readmissions for patients with heart failure. Over 2 years, the readmission rate dropped from 25.5% to 5.6%.

Why KangarooHealth is the Right Care Coordination Solution for Your Organization

You want to choose a care coordination solution that aligns with how your organization delivers care and also helps you solve resource constraints.

Here’s why KangarooHealth is the superior choice:

• Interoperability: EHR Integrations are necessary to prevent data silos that may hamper coordination. KangarooHealth integrates with popular EHR systems, including Epic, Cerner, and Athena. Further, we go beyond industry standards by delivering custom EHR integrations.
• Cost and time to launch: High hardware and software costs, along with long implementation times, are major barriers to entry. We eliminate these barriers by offering a turnkey implementation with no upfront costs. Also, our speedy implementation ensures you can go live in under 2 weeks.
• Alignment with your workflows: You should be able to implement care coordination without disrupting your clinical workflows. KangarooHealth supports 50+ chronic conditions with customizable care pathways, enabling you to design workflows that align with your clinical goals and the complexity of your patient population.

Also, we understand that care coordination succeeds when patients are active participants in their care journey. We empower your patients by providing tailored health coaching to help them better understand their conditions and take greater ownership of their health.

Book a demo of our solution to see how we can help you transform care coordination and remote patient care.

Frequently Asked Questions (FAQs)

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

What’s the Difference: Care Management vs. Care Coordination?

Care management involves the set of activities you require to assist a patient in managing their condition.

Care coordination focuses on how care and relevant data/information are communicated across providers and settings.

What is the Difference between Care Coordination and Case Management?

While care coordination synchronizes providers and settings, case management is the intensive process of managing patients with complex medical conditions.

It includes assigning a dedicated case manager and developing a personalized care plan.

What Are the Costs Associated With Care Coordination Tools?

Depending on the care coordination model/program and the vendor’s pricing formula, you may incur the following costs:

• Software licensing fees
• Cost of hardware (connected devices)
• Clinical staffing/outsourced clinical support services
• One-time or ongoing interoperability costs

What is the Future of Care Coordination in Healthcare?

There’s a steady shift towards continuous and more proactive care delivery models. You can expect care coordination to evolve in the following ways going forward:

• AI will play an increasingly bigger role in routing routine care coordination tasks.
• Interoperability will likely become a standard requirement across the board.
• To enable coordination at scale, some workflows will likely be embedded in standard healthcare solutions such as EHRs.
• To enable whole-person care, we’ll likely see greater integration of clinical and social care.

What Is Intensive Care Coordination?

Intensive care coordination refers to highly structured coordination services for patients with complex medical, behavioral, or social needs.

These patients often require multidisciplinary teams and ongoing monitoring.

Conclusion

As accountability for performance increases under value-based care, you must streamline care coordination to meet quality and cost targets.

However, superior coordination isn’t just about standardizing your communication workflows. You must also onboard technology that can support coordination with other providers while working seamlessly with your existing workflows.

That’s where KangarooHealth comes in. We can help you implement care coordination at scale through remote patient monitoring with custom EHR integrations and customizable workflows.

Schedule your free demo of KangarooHealth to experience our integrated approach to healthcare delivery.