What Is Coordinated Care?

When a team of health care providers uses a coordinated care approach, they work together to organize a patient’s health care plan to achieve the best possible outcomes.

The patient is actively engaged in their own care, and all team members understand the patient’s unique needs and preferences. The team clearly communicates with the patient, and each other, to ensure they deliver personalized care and support. Coordinated care is important for all patients, but it’s especially important for patients who may be managing multiple health conditions.

Most patients have a primary care provider (PCP) who’s cared for them over a long period of time. They are familiar with the patient’s health history, perform routine health screenings and help them manage common health conditions. PCPs refer patients to a specialist if the patient needs a diagnosis or special care for a more complex health condition like heart disease, cancer, or a behavioral health condition like substance use disorder.

“At the heart of the coordinated care approach is the primary care provider, who serves as the patient's advocate," explains Moshe A. Rancier, MD. Dr. Rancier is a primary care doctor with Mass General Brigham Community Physicians who cares for patients at Pentucket Medical. 

“This crucial role involves maintaining constant communication with specialists and the care team to ensure the patient's needs are met,” he adds. “By doing so, the PCP not only helps achieve desired health outcomes, but also prevents unnecessary hospital admissions. This enhances the patient's overall health and well-being.” 

How does coordinated care approach work?

Coordination of care can help ensure a patient gets individualized and efficient treatment and support at each step in their journey. Each health care provider:

• Understands the patient’s medical history, current needs, and health goals 

• Delivers the appropriate care at the right place and time

• Shares knowledge among the team to ensure everyone involved in the patient’s care is up to date on changes in the patient’s health, new bloodwork, imaging, medication, etc. 

• Participates in developing a holistic care plan to optimize the patient’s health outcomes 

• Monitors the patient’s progress and works with other providers to adjust the care plan as needed

• Addresses the patient’s questions and concerns

“This crucial role involves maintaining constant communication with specialists and the care team to ensure the patient's needs are met,” he adds. “By doing so, the PCP not only helps achieve desired health outcomes, but also prevents unnecessary hospital admissions. This enhances the patient's overall health and well-being.” 

What are the advantages of coordinated care?

Advantages of coordinated care include:

• Patients are empowered to be active members of their health care team.

• Health care providers foster strong relationships with patients and each other to ensure everyone understands the health care plan and goals.

• PCPs provide seamless referrals to trusted specialists for timely diagnosis and advanced treatment options.

• PCPs coordinate with specialists to help patients manage chronic conditions, such as diabetes or high blood pressure.

• Providers are familiar with a patient’s medical history and family health history proactively alert the care team to changes in a patient’s needs or care plan.

• Patient navigators schedule appointments and testing so that patients can get coordinated checkups, imaging and lab work in a convenient location.

• Team members connect patients to helpful resources including interpreter services, technology resources and support, financial assistance, community services, etc.

• Patients have optimal health care experiences due to proactive, clear communication across the team.

Convenient, coordinated care

“Our coordinated care approach at Mass General Brigham is designed to be seamless and efficient,” explains Dr. Rancier. “It allows PCPs to view all upcoming appointments, ensuring that the patient has the necessary labs and images in advance and is well-informed about the location and name of the specialist they will see. Additionally, PCPs can receive timely responses from specialists. When specialists see patients, they can review notes and results posted in our medical record system. This system enables the patient’s care team to easily discuss results and answer any questions, which makes the experience more seamless.”

“Effective care coordination by the primary care team improves health outcomes and positively impacts patient well-being,” says Dr. Rancier.