A recent systematic review of care coordination identified over 40 definitions of care coordination with many related terms used interchangeably, e.g., collaborative care, continuity of care, disease management, case management, care management, patient/care navigation (McDonald et al., 2007). 

Drawing together common elements of the definitions of care coordination and related terminology the following working definition was proposed:

"Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care."

See here or here for research on care coordination

According to The Commonwealth Fund, programs responsible for coordinating care often target "High-Need/High-Cost" patients with multiple or complex conditions, often combined with behavioral health problems or socioeconomic challenges as they require complex, multifaceted care (Read about challenges in defining High-Needs/High-Cost patients here).

Although High-Needs/High-Cost patients represent a small proportion of the patient population, they account for a substantial proportion of health care costs. 

The aim of care coordination in this population is to improve quality of care while reducing overall expenditures.

Sources: https://www.commonwealthfund.org/publications/case-study/2017/mar/caremore-improving-outcomes-and-controlling-health-care-spending-0; https://effectivehealthcare.ahrq.gov/products/high-utilizers-health-care/protocol; https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_issue_brief_2014_aug_1764_hong_caring_for_high_need_high_cost_patients_ccm_ib.pdf 

SHCN and EHCN are part of the Stepped Care Approach designed to deliver and monitor health coordination services so that the most effective, yet least resource-intensive treatments are delivered with members "stepping up" in frequency and intensity of services based upon member needs. Members "step down" to lower-level services when their needs decrease or are met. The system is designed to allow members to move seamlessly along the continuum of care.

Demonstration Objective 1

Improve health outcomes for Medicaid beneficiaries covered under the demonstration

Hypothesis 1.2

Improving care coordination (e.g. by establishing team-based care and greater integration of behavioral and physical health) will improve health outcomes and lower the total cost of care for beneficiaries with complex conditions (i.e. high-needs, high-cost individuals)

Key Evaluation Project

Project 1B: Care Coordination for Beneficiaries with complex conditions

Primary Driver(s)

1. Enhanced coordination for complex beneficiaries

Secondary Driver(s)

1. Greater identification / assessment of complex beneficiaries,

2. Enhanced coordination and increased community delegation, and

3. Team-based care

For more information on the activities, outputs, and metrics used to evaluate the SHCN Initiative, see the SHCN Logic Model

To see how Care Coordination for Complex Beneficiaries fits into the larger QUEST Evaluation Design, see HOPE Driver Diagram here in orange