Chronic Conditions - Key Activity 18


Coordinate Care


This key activity involves all seven elements of person-centered population-based care: proactive patient outreach and engagement; pre-visit planning and care gap reduction; care coordination; behavioral health integration; address social needs.


This activity will help you provide care that is person centered and coordinated across all internal and external providers involved with the patient.

Care coordination involves deliberately organizing patient care activities and sharing information among all participants concerned with a patient’s care to achieve safer processes and more effective outcomes.

Care coordination is an integral part of providing high-quality population-based care in an ambulatory care clinic. In your practice, care coordination happens daily as part of standard work and includes activities such as assisting patients with referrals, managing patient messages and receiving incoming information from outside care partners, including pharmacies, specialists, hospitals and community partners (e.g., schools, employers, community-based organizations).

Managing care across multiple settings is often a source of frustration and dissatisfaction for both patients and providers. Lack of coordinated care can result in both duplication of services and lack of completion of needed services. When care is not coordinated, decisions can be made without a complete picture of the patient’s needs and goals. Practices that have effective care coordination processes often employ closed loop referrals as a best practice.[1][2] In a closed loop referral, a referring provider can track the status of the referral (completed or pending) as well as the outcome of the referral, including whether additional follow-up is needed. When closed loop referrals are implemented, both provider and patient satisfaction are enhanced.

There are four fundamental concepts when thinking about care coordination activities within your practice:[3]

  • Accountability:
    A key to successful care coordination is accountability. Clinics and systems that excel at care coordination take ownership and assume responsibility for care coordination activities. Examples of care coordination processes include development of infrastructure for care coordination, identification of staff responsibilities and relationship building with referral partners. Together, these actions create the ability to support referrals and transitions and track them to completion.
  • Patient support:
    Referrals and transitions often raise questions for patients and families and can be a source of anxiety. Not only do the logistics of a referral or transition create questions, but patients and their families can experience anxiety regarding the outcome or purpose of a referral or transition. When a practice can dedicate staff time to addressing the needs of patients and families, referrals and transitions are most likely to accomplish intended goals.
  • Relationships and supports:
    Referrals and transitions work best when all parties – patients, primary care providers, and consultants – agree on the purpose and importance of the referral, as well as the roles that each will play in providing care.
  • Connectivity:
    Building relationships and agreements among providers (including community agencies) leads to shared expectations for communication and care. Connectivity includes developing referral relationships, accepting accountability and creating data flow.

In order to conceptualize how practices can coordinate with community-based agencies (housing, food, income support), hospitals and ERs, and specialists, refer to the visual depiction of the care coordination model by the Center for Accelerating Care Transformation (ACT Center).

Care coordination can benefit all patients in your practice. Care coordination processes, such as closed loop referrals, can be applicable to many practice activities (see examples below in figure 20). Common areas where care coordination can be enhanced include specialty referrals and referrals to social supports, such as transportation and housing assistance. Care coordination activities can also identify patients who need a higher level of support through a care management program (see Key Activity 21: Provide Care Management). Care management differs from care coordination in that a patient consents to and works directly with a care manager to create a care plan that is shared with an extended care team. While a practice can decide whether it has the resources to provide higher-level care management services, care coordination is a foundational activity of effective population health management.

Patients with Medi-Cal have access to many resources that can support improved health outcomes and address social needs. These Medi-Cal resources can be another opportunity to create care coordination processes in your practice; see Figure 18 for a partial list of Medi-Cal programs that involve care coordination. As of 2023, both doula care and community health worker services are benefits of the Medi-Cal program. Doulas provide evidence-based, culturally competent (racial, ethnic, linguistic) services aimed at preventing perinatal complications and improving health outcomes for birthing. The services of community health workers (also known as Promotores/Community Health Resources) can be highly effective in helping to connect patients to resources and educational materials that are community based and aligned with a patient’s values, language and cultural needs to further health equity. The California Health Care Foundation offers an overview of the community health worker program, including potential hurdles.

Medi-Cal patients with high medical, behavioral health and/or social needs may be eligible for ECM and Community Supports (see Key Activity 21: Provide Care Management for more information on these programs).

There are also a number of Medi-Cal programs that provide services and support to Medi-Cal patients who qualify. Care coordination between the practice and these programs can result in more integrated care for eligible patients. Long-term services and supports, which are available to support individuals in the community, are examples. These include skilled nursing facility services, personal care services, self-directed personal assistance services, in-home supportive services, and home and community-based services. Figure 18 provides a high-level overview of care coordination opportunities.



  • Enhanced Care Management
  • Community Supports
  • Community Health Workers
  • Doula
  • Long term services and supports (LTSS)
  • California Children’s Services (CCS)

Effective care coordination helps your practice to better meet the broad range of patient needs and preferences. It helps ensure that each patient’s needs and preferences are known and communicated at the right time to the right people and that this information is used to guide the delivery of safe, appropriate and effective care.

Key outcomes of care coordination are:

  • Greater patient participation and satisfaction.
  • Closed gaps and inequalities in access to care addressed.
  • Improved quality outcomes and potential to leverage quality financial incentives.
  • Decreased staff burnout and duplication of services (i.e., “let the system do the work”).

Effective care coordination helps to reduce health inequities and address social needs among different populations by better identifying and then working to address a broad range of patient needs. When care coordination is effective, the patient is at the center of care and the patient's cultural, social and health needs are incorporated into a plan of care. By identifying outside clinical supports (e.g., hospital care, specialist care) and social supports (e.g., housing, transportation and food assistance) and creating pathways for coordination, the practice promotes equity by facilitating access to these services for all patients who need them. As part of a care coordination strategy, practices should consider the growing number of “aggregator” organizations (see the “Resources” section below) that partner with community-based programs and resources centered around addressing social needs, such as housing, food and community. Many of these community-based programs are tailored for specific demographic groups and can support patients in meeting their needs in a culturally competent way.

Technology can be used to streamline and enhance care coordination. Care coordination technology tools can support care coordination activities such as registry, clinical decision support, care gap reporting, and patient outreach and engagement. See additional considerations under the “Address connectivity” section below.

Practices can use a care coordination self-assessment tool, such as those referenced in the action steps below) to determine if additional technology support would be indicated.

Registry and care gap reporting

Practices can use an analytics platform to identify patients and group patients together who have similar needs. Your practice can then tailor interventions to meet the needs of a population. For example, a practice can use data to identify those people who have not had a visit in the past year or those who are due for colon cancer screening. Data can come directly from the medical records or from claims data that is submitted to the payor.

Care coordination software: clinical decision support

Many EHRs have care coordination modules that can be used to develop assessments and care plans. Alternatively, care coordination modules can be add-ons to EHRs. Care coordination software can support assessment, referral and coordination pathways (clinical decision-making support). Using a care coordination software module, a practice can develop an assessment with questions regarding a patient’s social health needs. If answers are positive, the software can be configured to provide referral pathways and prompt care coordination activities. For example, if a patient answers “yes” to questions on food insecurity, the assessment can prompt referral to local resources such as food banks, meal programs and nutritional supports. The system can also prompt the staff to reassess progress at the next visit.

See Appendix E: Guidance on Technological Interventions.

Action steps and roles

The action steps and roles outlined below provide a framework for assessing current state of care coordination, developing a strategy, implementing care coordination, and monitoring and learning as you progress.


1. Establish a “call to action” for care coordination.

Suggested team member(s) responsible: medical lead or care coordination staff or QI staff.

To achieve effective care coordination, your practice needs to see itself as a “hub” or “center” for coordination of patient care.

  • While all clinicians within a patient’s support network need to collaborate, your practice should view itself as accountable for care coordination for empaneled patients and patients who have been assigned to your practice by their MCP.
  • Identify a care coordination team that will be responsible for leading the evaluation, assessment and implementation of care coordination activities.
  • Share with the care coordination team why care coordination is important.
  • Some areas to address:
    • Discuss what care coordination is.
    • Discuss why care coordination benefits staff and patients.
    • Review proposed framework (assess, develop strategy, implement, monitor) to develop the care coordination activity.
    • Identify and share some initial projects that are directed at enhancing care coordination.
    • Invite and engage staff and patients to provide input on how they think care coordination can be enhanced.
    • Discuss how best to incorporate feedback from patients.

Use feedback from this activity and incorporate it into an assessment.


2. Assess your practice’s current state of care coordination activities.

Suggested team member(s) responsible: panel manager and QI lead.

Begin by asking and answering the following questions:

  • What does the practice hope to achieve by implementing interventions to change the care coordination process?
  • Which patient needs are the responsibility of the practice to provide (care coordination within the practice)?
  • Which patient needs will need to be addressed through external referral and collaboration (care coordination with entities outside the practice)?

What resources are needed to improve the current state (data; input from care team members; input from care partners such as hospitals, specialty, behavioral health, social needs)?

Gather stakeholder input.

  • Conduct interviews or surveys with patients and community members to understand their perspectives on current care coordination processes, challenges and areas for improvement.
  • Conduct interviews with your care team to understand their perspectives on current care coordination processes, challenges and areas for improvement.

Analyze existing systems and processes.

  • Review existing care coordination protocols, technologies and resources utilized by health centers.
  • Explore how technology is currently being used to support care coordination. Then explore how technology could be harnessed to streamline care coordination, improve data sharing and/or enhance communication among clinicians.
  • Review existing formal and informal linkage agreements.
  • Conduct an analysis to determine patient needs not yet fully addressed by existing agreements.
  • Assess data on patient outcomes, patient satisfaction and any existing QI initiatives.
  • The following resources can help your practice assess its current state:


3. Develop and implement a care coordination improvement strategy.

Suggested team member(s) responsible: panel manager and QI lead.

Develop your high-level care coordination improvement strategy.

  • The high-level strategy is based on the results and insights from your Care Coordination Maturity Assessment and your practice’s capacity (bandwidth).
  • Establish clear objectives.
  • Define specific, measurable, achievable, relevant, time-bound, inclusive and equitable (SMARTIE) goals for enhancing care coordination.
  • Ensure that these goals align with the overall mission and values of your practice.
  • Prioritize areas for improvement: Identify a limited set of key focus areas based on the assessment findings and your practice’s bandwidth, such as communication protocols, technology integration, staff training or patient engagement strategies.

Identify resources and infrastructure.

  • As part of the implementation of the strategy, identify the resources and infrastructure needed to support care coordination at your practice.

We have included in Figure 19 below some considerations, by resource, as you develop your care coordination implementation plan (some of the resources may not apply to your practice).






Dedicated time for the development, training and implementation of CC activity. Defining ongoing staffing needs.

Internal tools

Electronic health record modifications. Data needs and technology needed to implement CC activity.


Development of workflows, training materials, communication plan and job descriptions. Identification of what CC activities will be the responsibility of the practice staff.

Funding and finance

Explore benefits such as Enhanced Care Management or community health workers, as well as financial resources that may be available through external partners, such as health plans and hospitals.

Clinical decision-making support

Medical staff, behavioral health and social work and patients as subject matter experts (SMEs).

External support and data

Information and resources required from the entity with  which the clinic is coordinating (e.g., hospital, specialist, social health provider). Data exchange requirements including the new California Data Exchange Framework (DxF).

Develop staffing for care coordination.

Determine who at your practice will be involved in care coordination. The PHMI Care Teams and Workforce Guide Resource 1: Core and Expanded Care Team Functions, Team Members and Roles provides an overview on care coordination using a care coordinator or referral manager.

  • Based on the population of focus and the intervention, develop staffing requirements and any job description changes to embed care coordination into your practice.
  • The responsibilities of a person/people fulfilling care coordination roles should include, at a minimum:
    • Manage the referral process.
    • Assist patients with transitions, such as those to and from hospitals and other institutions.
    • Help patients resolve logistical, financial and/or other barriers to a successful referral.
    • Link patients with community resources.
    • Follow up with patients within a few days of an emergency room visit, hospital discharge or discharge from a treatment facility.
    • Ensure the safe transfer of patient data.
    • Track progress (referral milestones).
    • Assist patients who are having difficulties.
    • Schedule follow-up and specialty appointments for/with patients
  • Formalize the referral coordinator role through a job description or position description. Sample referral coordinator position description.
  • Provide regular training and support to care coordinator/referral coordinator or similar.

Develop or refine your policies and procedures for care coordination. At a minimum, this should include all of the following:

  • Identifying patients who are eligible for care coordination.
  • Defining the activities that are associated with care coordination (outreach, engagement, assessment, desired outcome).
  • Managing the referral process.
  • Ensuring the safe transfer of patient data.
  • Tracking progress – closed loop referral.
  • Identifying patients who would benefit from higher levels of care coordination, such as care management interventions like ECM (see Key Activity 21: Provide Care Management.)

Develop or refine your referral protocols.

Develop clear guidelines for when and how to make clinical referrals.

  • Include criteria for urgent versus nonurgent referrals.

For each clinician your practice will be referring to:

  • Identify the information, format and process the clinician requires to receive a referral.
  • Share the information you will need back from the clinician (when the referral has been successfully made and/or once the service or support has been provided) to ensure continuity of care and nonduplication of services.
  • Formalizing this through a written agreement or compact is a good way to ensure expectations on both sides of a referral are understood.

In working with community agencies or organizations that provide social support, the specific information that can and should be shared will depend on the service. It is important to have a mutual understanding about that information, using a written agreement where possible. At minimum, if the referral did not include a warm handoff, there should be an expectation that the practice hears back from the organization to let them know whether the patient followed up on the referral. See: Sample primary care checklist suggestions for assessing referral process.

Address connectivity. For any clinicians that you are exchanging patient data with, your practice should develop formal agreements and processes. Below are some considerations to facilitate information sharing among clinicians involved in an individual’s care:

  • Integrate documentation platforms where possible and standardize how documentation is included in patient records.
  • Ensure that behavioral health records are integrated into the overall EHR system to the extent permitted by law.
  • Enable clinicians to access comprehensive patient information.
  • Identify and assess participation in health information exchanges and/or social health information exchange systems, where feasible, to facilitate seamless sharing of patient information. These exist in some communities and will develop over time. This explainer series from the California Health Care Foundation describes the new statewide health information exchange coming into effect in 2024.
  • Understand when patient consent is required to ensure compliance with privacy regulations, such as the Health Insurance Portability and Accountability Act. Include consent processes in the referral protocols.
  • Set expectations about the information that should be shared and develop processes for facilitating that exchange. As data that is used in a clinical setting will likely be different than information that is shared by community agencies or social support networks, it is imperative to have clear parameters around what types of information can be exchanged between your practice and your partners.

Provide care coordination to patients.

In accordance with your care coordination policies and procedures and referral protocols, provide care coordination to patients who need it.

Embed care coordination into your practice’s daily workflow, including PVP. See Key Activity 10: Develop or Refine and Implement a Pre-Visit Planning Process.

Provide referrals to care management (See: Key Activity 21: Provide Care Management) such as ECM for patients who require more intensive support.

Discuss each referral with the patient to ensure the patient understands the reason for the referral.

Below is an example of a care coordination QI strategy.



Area of Improvement


Why It Is Important

Development of registries and process to outreach to empaneled patients who have not engaged in care.

Bring individuals into care and screen for social health needs/barriers.

Supports increased access to preventive medical care and addresses barriers related to social health.

Development of a closed loop referral pathway for social services when social health barriers are identified.

Support patients in receiving services that will be beneficial to addressing social health barriers, including those that are culturally aligned and based in communities where they live.

Health outcomes, including health equity and access, are improved when social health needs are met.

Development of a referral pathway to specialty clinicians and the creation of a pathway to receive consult results.

Optimize access to specialty services, including urgent referral, and ensure consultation results are available to the PCP.

Ensures timely access for services, including urgent referrals. Receipt of consult information saves time and prevents duplication of services.

Development of a process to follow up with patients after transitions of care, posthospitalization.

Support optimal outcomes for patients after hospitalization and decrease the chance of rehospitalization.

The transition from the inpatient (hospital) setting back to home often results in poor care coordination, which can lead to medication errors, repeated or incomplete diagnostic work-up and lack of clarity regarding what a patient needs after hospitalization.

The following resources can help your practice develop your care coordination improvement strategy:


 4. Monitor continuous QI of care coordination

Suggested team member(s) responsible: QI lead.

Develop both formal and informal mechanisms to obtain feedback from clinicians, staff and patients on the effectiveness of your practice’s care coordination efforts and to identify areas for improvement.

Establish key performance indicators related to care coordination. Consider using AHRQ’s Care Coordination Quality Measures for Primary Care (CCQM-PC). Your performance indicators will vary based upon your improvement strategy and the needs of patients, but they may include metrics such as:

  • Number of assigned patients engaged in care.
  • Number of individuals with hypertension whose blood pressure is controlled.
  • Percentage of closed loop referrals by referral entity. Monitor and analyze metrics to gauge the effectiveness of your internal systems and how well each referral partner is promoting coordination and collaboration.

Continue to build relationships with clinicians and community support agencies that are available to provide services to patients.

Consider developing and using a care coordination variance report. Here is a sample patient care coordination variance report.

Implementation tips

  • An interoperable referral management system can help practices streamline the intake process, communicate with other clinicians and social service agencies, track the status and outcomes of referrals, and ensure that patients receive the appropriate level of care and support.
  • Leverage community health information exchanges to gain access to admission, discharge and transfer information. Absent being able to access a health information exchange, establish relationships with your local hospitals to be able to gain daily notification of your patients being discharged.


  1. Patel, M.P., Schettini, P., O’Leary, C.P. et al. Closing the Referral Loop: an Analysis of Primary Care Referrals to Specialists in a Large Health System. J GEN INTERN MED 33, 715–721 (2018). 
  2. American College of Physicians. Transforming Clinical Practice Initiative SAN Power Packs: Closing the Loop. Centers for Medicare & Medicaid Services; 2019. Available from: 
  3. Reducing Care Fragmentation: A Toolkit for Coordinating Care [Internet]. The Center for Accelerating Care Transformation. The Commonwealth Fund; 2010. Available from: