The following blog post was written by Heather Banks, a Healthcare Transformation Coordinator at RMS.

Care Coordination is paramount to ensuring management and delivery of quality-centered patient-care. The goal of care coordination is to make the primary care practice the hub of all patient care. Not only must care coordination be within the practice, but in order to effectively coordinate patient care, the primary care practice must develop relationships between the community setting, hospitals, labs and specialists. They must create protocols to support successful referrals and transitions; and develop systems to handle the transfer of pertinent information. The responsibility of PCMH is not just to inform those community providers, but to reach out and connect with them in meaningful and impactful ways so that information is communicated appropriately, consistently and without delay. Putting a care coordination program or care coordinator in place will significantly improve quality of care and patient satisfaction. Utilizing the expertise of a Care Manager will significantly contribute to improved quality of care; patient outcome, and could positively impact a patient’s overall experience.


To improve accountability and prevent care from being fragmented, consider these five steps:

  • Assign a dedicated person/team to be accountable for managing patient care.
  • Define the extent of responsibilities for key activities.
  • Establish when specific responsibilities should be transferred to other providers whether that means specialty physicians, long-term care facilities, or home care providers.
  • Share clinical information and findings about patients who are in the hospital.
  • Ensure that referrals to specialist physicians are made and completed.

Providers need to understand why this is so important to their practices. In some instances, communication breaks down between the providers and facilities; which can lead to unnecessary hospitalizations, duplicate tests and procedures, medical and medication errors, among other problems. Having a Care Coordinator in place reduces these risks and healthcare costs by preventing avoidable hospitalizations and emergency room use.

There are four key steps that a primary care setting need to do to implement Care Coordination within the practice setting:

  • Assume Accountability
    • Decide to improve care coordination.
    • Develop a quality improvement plan to implement change.
    • Develop a tracking system to internally track and manage the referral process and transition of care.
  • Provide Patient Support
    • Train the care team in effective communication and in their duties in order to support patients and families.
    • Assess patient’s clinical needs as well as insurance and logistical needs.
    • Identify patient barriers and help address them. Be sure the patients are well informed and help them understand the reason for the referral to an outside specialist or other facility.
    • Engage the patients to talk about their care after a hospitalization or ER visit, ask them if there have been any visits to specialists or behavioral health professionals. Also ask if any medication changes have occurred outside of the PCPs office.
    • Provide the patient with a discharge check list preparing them to leave a hospital or long-term care facility.
    • Communicate patients’ needs and preferences to all staff providing care.
    • Ensure the care team follows-up with the patient post-hospitalization or ER visits within an appropriate period of time. Educate the patient on the appropriate usage of the ER or if it is something that should be taken care of in the primary care setting.
    • Identify barriers or problems that will prevent the patient from not keeping their referral appointment.
  • Build Relationships and Agreements
    • Develop and maintain relationships with key specialists, hospitals and community agencies. Become the building block for these relationships with these providers and facilities.
    • Develop verbal or written agreements that include expectations and guidelines for referral and care transition processes to keep all parties informed of any clinical developments and to ensure compliance.
    • Set clear expectations on how information will be shared.
    • Make sure the referring and consulting providers understand the importance of the referral, and the roles that each will play in providing care by implementing a standard communication protocol.
    • Be sure the information in the referral requests and consultation reports meets agreed expectations.
  • Develop Connectivity
    • Establish an EHR system that can share information so that accurate and updated patient information can be sent easily to other providers.
    • Enable live data-sharing so physicians can immediately see changes in medications and test results.
    • Establish the ability to send alerts to providers when patients have been seen to the hospital so they can follow up.
    • Implement an information transfer system and assign specific individuals on the care team to help patients and their information get where it needs to go.
    • Designate an on-site staff member who will be an expert in the EHR system and can trouble shoot problems.
    • Open communication with other providers about patients as a way of two-way communication to follow up on information received through the EHRs.

Effective communication is the foundation of any health care team. Errors in communication can have grave consequences in the health care setting. Everyone in the health care community has a role to play by working together to achieve exceptional care coordination. Practicing effective care coordination will provide significant benefits to the implementing practice.

RMS Healthcare, a division of Research and Marketing Strategies, Inc. (RMS) has over 50 years of collective and proven experience in providing consulting services to meet the specific needs of our clients. Regardless of your healthcare research or practice transformation needs, RMS Healthcare can help.  If you are interested in learning more, please contact Susan Maxsween, Senior Director, Healthcare Operations and Compliance at or via telephone at 1-866-567-5422.