Technical Review 

Number 9 

Closing the Quality Gap: 

A Critical Analysis of Quality Improvement Strategies 

Volume 7—Care Coordination 

Prepared for: 

Agency for Healthcare Research and Quality 

U.S. Department of Health and Human Services 

540 Gaither Road 

Rockville, MD 20850 

www.ahrq.gov 

Contract No. 290-02-0017 

Prepared by:

Stanford University–UCSF Evidence-based Practice Center, Stanford, CA 

Series Editors 

Kaveh G. Shojania, M.D., University of California, San Francisco 

Kathryn M. McDonald, M.M., Stanford University 

Robert M. Wachter, M.D., University of California, San Francisco 

Douglas K. Owens, M.D., M.S., VA Palo Alto Health Care System, Palo Alto, California; 

Stanford University

Investigators 

Kathryn M. McDonald, M.M. 

Vandana Sundaram, M.P.H. 

Dena M. Bravata, M.D., M.S. 

Robyn Lewis, M.A. 

Nancy Lin, Sc.D. 

Sally A. Kraft, M.D., M.P.H. 

Moira McKinnon, B.A. 

Helen Paguntalan, M.S. 

Douglas K. Owens, M.D., M.S. 

AHRQ Publication No. 04(07)-0051-7 

June 2007
This report is based on research conducted by the Stanford-UCSF Evidence-based Practice Center 

(EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD 

(Contract No. 290-02-0017). The findings and conclusions in this document are those of the 

author(s), who are responsible for its contents, and do not necessarily represent the views of 

AHRQ. No statement in this report should be construed as an official position of AHRQ or of the 

U.S. Department of Health and Human Services. 

The information in this report is intended to help clinicians, employers, policymakers, and others 

make informed decisions about the provision of health care services. This report is intended as a 

reference and not as a substitute for clinical judgment. 

This report may be used, in whole or in part, as the basis for development of clinical practice 

guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage 

policies. AHRQ or U.S. Department of Health and Human Services endorsement of such 

derivative products may not be stated or implied. 
ii 

This document is in the public domain and may be used and reprinted without permission except 

those copyrighted materials noted for which further reproduction is prohibited without the 

specific permission of copyright holders. 

Suggested Citation: 

McDonald KM, Sundaram V, Bravata DM, Lewis R, Lin N, Kraft S, McKinnon M, Paguntalan 

H, Owens DK. Care Coordination. Vol 7 of: Shojania KG, McDonald KM, Wachter RM, 

Owens DK, editors. Closing the Quality Gap: A Critical Analysis of Quality Improvement 

Strategies. Technical Review 9 (Prepared by the Stanford University-UCSF Evidence-based 

Practice Center under contract 290-02-0017). AHRQ Publication No. 04(07)-0051-7. Rockville, 

MD: Agency for Healthcare Research and Quality. June 2007.

None of the investigators has any affiliations or financial involvement that conflicts 

with the material presented in this report. 
 iii

Preface 

 The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-Based 

Practice Centers (EPCs), sponsors the development of evidence reports and technology 

assessments to assist public- and private-sector organizations in their efforts to improve the 

quality of health care in the United States. The reports and assessments provide organizations 

with comprehensive, science-based information on common, costly medical conditions and new 

health care technologies. The EPCs systematically review the relevant scientific literature on 

topics assigned to them by AHRQ and conduct additional analyses when appropriate prior to 

developing their reports and assessments. 

 To bring the broadest range of experts into the development of evidence reports and health 

technology assessments, AHRQ encourages the EPCs to form partnerships and enter into 

collaborations with other medical and research organizations. The EPCs work with these partner 

organizations to ensure that the evidence reports and technology assessments they produce will 

become building blocks for health care quality improvement projects throughout the Nation. The 

reports undergo peer review prior to their release. 

 AHRQ expects that the EPC evidence reports and technology assessments will inform 

individual health plans, providers, and purchasers as well as the health care system as a whole by 

providing important information to help improve health care quality. 

 We welcome comments on this evidence report. They may be sent by mail to the Task Order 

Officer named below at: Agency for Healthcare Research and Quality, 540 Gaither Road, 

Rockville, MD 20850, or by e-mail to epc@ahrq.gov. 

Carolyn M. Clancy, M.D. 

Director 

Agency for Healthcare Research and Quality 

Beth A. Collins Sharp, Ph.D., R.N. 

Director, EPC Program 

Agency for Healthcare Research and Quality 

Jean Slutsky, P.A., M.S.P.H. 

Director, Center for Outcomes and Evidence 

Agency for Healthcare Research and Quality 

Marian D. James, Ph.D., M.A. 

EPC Program Task Order Officer 

Agency for Healthcare Research and Quality
 iv

Acknowledgments 

We thank Marilyn Tinsley at the Stanford University Lane Library for her help with the literature 

searches; Juan Carlos Montoy for assistance with thoughtful background research during the 

scope setting stage; our AHRQ colleagues David Atkins, M.D., Kenneth Fink, M.D. (previously 

at AHRQ), Susan Norris, M.D. (previously at AHRQ) and Marian James, Ph.D. for their 

guidance in determining the appropriate scope for this undertaking and their comments on earlier 

drafts of this report; and Merrick Zwarenstein, M.B., B.Ch., M.Sc. and James L. Zazzali, Ph.D. 

for guidance and thoughtful discussions on the definitions and conceptual frameworks chapters. 

We also acknowledge with much gratitude our expert advisors and peer reviewers, who are listed 

in Appendix D*

. Ms. Sundaram and Dr. Owens were supported by the Department of Veterans 

Affairs. Dr. Kraft was supported by the Palo Alto Medical Research Institute.

 

*

 Appendixes cited in this report are provided electronically at http://www.ahrq.gov/clinic/tp/caregaptp.htm 
 v

Structured Abstract 

Context: Quality problems and spiraling costs have resulted in widespread interest in solutions 

that improve the effectiveness and efficiency of the health care system. Care coordination has 

been identified by the Institute of Medicine as one of the key strategies for potentially 

accomplishing these improvements. 

Objectives: The objectives of this project were to develop a working definition of care 

coordination, apply it to a review of systematic reviews, and identify theoretical frameworks that 

might predict or explain how care coordination mechanisms are influenced by factors in the 

health care setting and how they relate to patient outcomes and health care costs. 

Data Sources and Review Methods: We used literature databases, Internet searches, and 

personal contacts to assemble background information on ongoing care coordination programs; 

potential definitions; conceptual frameworks and related empirical evidence; and care 

coordination measures. We also conducted literature searches through September 30, 2006 of 

MEDLINE®, and November 15, 2006 for CINAHL®, Cochrane database of systematic reviews, 

American College of Physicians Journal Club, Database of Abstracts of Reviews of Effects, 

PsychInfo, Sociological Abstracts, and Social Services Abstracts to identify systematic reviews 

of care coordination interventions. We excluded systematic reviews with a narrow focus, 

namely those conducted solely in the inpatient setting, or where the only two participants 

involved in care were the patient and a health care provider. 

Results: We identified numerous ongoing programs in the private and public sector, most of 

which have not yet been evaluated. We identified over 40 definitions of care coordination and 

related terminology, and developed a working definition drawing together common elements: 

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 marshalling 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. 

We used this definition to develop our inclusion/exclusion criteria for selecting potentially 

relevant systematic reviews. Our literature search yielded 4,730 publications, of which 75 

systematic reviews evaluating care coordination interventions, either fully or as a part of the 

review, met inclusion criteria. From these, we identified 20 different coordination interventions 

(e.g., multidisciplinary teams, case management, disease management) covering 12 clinical 

populations (e.g., mental health, heart disease, diabetes) and conducted in multiple settings (e.g., 

outpatient, community, home). Finally, we identified four conceptual frameworks (Andersen’s 

behavioral framework, Donabedian’s structure-process-outcome framework, Nadler/Tushman 

and others’ Organizational design framework with Wagner’s Chronic Care Model provided as an 

example of such design, and Gittell’s Relational coordination framework) with potential 

applicability to studying care coordination by assessing baseline characteristics of the 

environment, specific coordination mechanism alternatives, and outcomes. The strongest 

evidence shows benefit of care coordination interventions for patients who have congestive heart 
 vi

failure, diabetes mellitus, severe mental illness, a recent stroke, or depression, though evidence 

about key intervention components is lacking. 

Conclusions: Care coordination interventions represent a wide range of approaches at the 

service delivery and systems level. Their effectiveness is most likely dependent upon 

appropriate matching between intervention and care coordination problem, though more 

conceptual, empirical and experimental research is required to explore this hypothesis. 
 vii

Contents 

Executive Summary.........................................................................................................................1 

Technical Review .........................................................................................................................11 

Chapter 1. Introduction .................................................................................................................13 

 1A Report Scope and Organization ........................................................................................13 

 1B Key Research Questions....................................................................................................14 

Background: Ongoing Efforts in Care Coordination and Gaps in the 

Evidence (Chapter 2) ...................................................................................................14 

Definitions of Care Coordination and Related Terms (Chapter 3)....................................14 

Review of Systematic Reviews of Care Coordination Interventions (Chapter 4) .............15 

Conceptual Frameworks and Their Application to Evaluating Care Coordination 

Interventions (Chapter 5) .............................................................................................15 

 1C Peer Review.......................................................................................................................15 

Chapter 2. Background: Ongoing Efforts in Care Coordination and Gaps in the Evidence .......17 

 2A Care Coordination Vendors ..............................................................................................18 

 2B Purchasers and Developers of Care Coordination Programs ............................................19 

 Medicare ............................................................................................................................19 

 State Medicaid Programs ...................................................................................................22 

 Department of Veterans Affairs.........................................................................................24 

 Other Federal Programs .....................................................................................................25 

 Private Sector Developers and Purchasers.........................................................................25 

 2C Professional Specialty Associations..................................................................................26 

 2D Patient and Family Associations.......................................................................................27 

 2E Conferences .......................................................................................................................27 

 2F Other Activities Described by Care Coordination Professionals ......................................28 

 Questions of Interest to Care Coordination Decisionmakers.............................................28 

 Key Gaps in the Care Coordination Evidence Base ..........................................................30 

 2G Summary Answers to Key Questions ...............................................................................30 

 Research Question 1: What Aspects of Care Coordination Are of Greatest Interest to 

Healthcare Decisionmakers?........................................................................................30 

 Research Question 2: What Are the Key Gaps in the Care Coordination 

 Evidence Base? ............................................................................................................31

Chapter 3. Definitions of Care Coordination and Related Terms.................................................33 

 3A Background and Objectives ..............................................................................................33 

 3B Methodological Approach.................................................................................................33

 3C Key Elements in Care Coordination Definitions...............................................................33 

 Participants Involved in a Patient’s Care...........................................................................39 

 Interdependence of Participants.........................................................................................40 

 Adequate Knowledge About Available Resources and Participants’ Roles......................40 
 viii

 Information Exchange Among Participants.......................................................................41 

 The Aims of Care Coordination.........................................................................................41 

 3D Proposed Working Definition of Care Coordination ........................................................41 

 3E Terminology Closely Related to Care Coordination.........................................................41 

 Collaboration......................................................................................................................42 

 Teamwork ..........................................................................................................................42 

 Continuity of Care..............................................................................................................42 

 Disease Management .........................................................................................................43

 Case Management..............................................................................................................43 

 Care Management ..............................................................................................................43 

 Chronic Care Model...........................................................................................................44 

 Care Navigator or Patient Navigator..................................................................................44 

 3F Components of Care Coordination ....................................................................................45 

 3G Summary Answers to Key Questions ...............................................................................49 

 Research Question 3: What Definitions Exist for Care Coordination? ............................49 

 Research Question 4: What Definition Could be Formulated To Apply to Systematic 

Reviews?......................................................................................................................49 

Chapter 4. Review of Systematic Reviews of Care Coordination Interventions..........................51 

 4A Background .......................................................................................................................51 

 4B Methodological Approach.................................................................................................51

Inclusion and Exclusion Criteria........................................................................................51 

Search Strategy ..................................................................................................................51 

Data Abstraction and Evaluation .......................................................................................52 

Quality Assessment of Reviews.........................................................................................52 

Statistical Analysis.............................................................................................................52 

 4C Results ...............................................................................................................................53 

 Results of Literature Search and Article Review Process .................................................53 

Summary of Reviews With Entire Focus on Care Coordination.......................................54 

Quality Assessment of Reviews.........................................................................................54 

Systematic Review Characteristics....................................................................................59 

Care Coordination Strategies .............................................................................................61 

Outcomes Reported............................................................................................................62

Costs...................................................................................................................................64 

 Narrative Syntheses of Selected Systematic Reviews by Care Coordination Strategy ...........67 

 Systematic Reviews Evaluating Multidisciplinary Teams as a Care 

Coordination Strategy ..................................................................................................67 

Systematic Reviews Evaluating Disease Management as a Care 

Coordination Strategy ..................................................................................................70 

Systematic Reviews Evaluating Case Management as a Care Coordination 

Strategy ........................................................................................................................72 

Systematic Reviews Evaluating Integrated Care as a Care Coordination Strategy...........73 

Systematic Reviews Evaluating Interprofessional Education as a Care 

Coordination Strategy ..................................................................................................74 
 ix

Narrative Syntheses of Systematic Reviews by Selected Clinical Topic, 

Population, and Setting ......................................................................................................74

Systematic Reviews of Care Coordination Strategies Among Patients With 

Mental Health Problems ..............................................................................................74 

Systematic Reviews of Care Coordination Strategies Among Patients 

With Heart Failure .......................................................................................................75 

Systematic Reviews of Care Coordination Strategies Among Patients 

With Diabetes...............................................................................................................76 

Systematic Reviews of Care Coordination Strategies Among Elderly Patients................76 

Systematic Reviews of Care Coordination Strategies Across Settings .............................76 

 Summary of Reviews With Partial Focus on Care Coordination ......................................95 

Narrative Synthesis of Recent Systematic Reviews by Coordination Component................102 

 4D Discussion .......................................................................................................................105 

 4E Limitations.......................................................................................................................105 

 4F Summary Answers to Key Questions..............................................................................106 

Research Question 5: Which Care Coordination Interventions Have Been 

Evaluated by Systematic Reviewers and How Were They Defined?........................106 

Research Question 6: What is the Evidence Regarding the Health Benefits 

of These Care Coordination Interventions as Summarized in the 

Systematic Review(s)? In Particular, is the Effectiveness of Care 

Coordination Intervetions Related to the Setting in Which Care 

is Being Coordinated, the Component of Care Being 

Coordinated, or the Type of Disease or Patients for 

Whom Care is Being Coordinated? ...........................................................................106 

Research Question 7: Have the Costs of Care Coordination Interventions Been 

Evaluated in any of These Systematic Reviews, and if so What is Known?.............107 

Chapter 5. Conceptual Frameworks and Their Application to Evaluating Care 

 Coordination Interventions ....................................................................................................109 

 5A Background .....................................................................................................................109 

 5B Methodological Approach...............................................................................................109 

 Focusing the Conceptual Frameworks on Key Decisionmakers .....................................110 

 5C Results .............................................................................................................................110 

Model 1: The Andersen Behavior Framework ...............................................................111 

Model 2: Donabedian’s Quality Framework ..................................................................113 

Model 3: The Organizational Design Framework ..........................................................114 

Model 4: The Relational Coordination Framework........................................................119 

Summary of Concepts From Frameworks .......................................................................121 

Measures Related to Care Coordination ..........................................................................122 

 5D Summary Answers to Key Questions .............................................................................128 

Research Question 8: What Concepts Are Important To Understand and Relate 

to Each Other for Evaluations of Care Coordination? What Conceptual 

Frameworks Could be Applied To Support Development and 

Evaluation Strategies To Improve Care Coordination?.............................................128 
 x

Research Question 9: What Measures Have Been Used To Assess 

Care Coordination? ....................................................................................................129 

Research Question 10: How do These Frameworks Relate to Quality 

Improvement Strategies Evaluated in the Previous Closing the 

Quality Gap Series Reports?......................................................................................130 

Chapter 6. Conclusions ...............................................................................................................131 

Improving Care Coordination................................................................................................131 

 Recommendations for Future Research.................................................................................136 

References and Included Reviews ...............................................................................................139 

List of Acronyms/Abbreviations..................................................................................................157 

Figures 

Figure 1. Search results ...............................................................................................................53 

Figure 2. Quality assessment of reviews.....................................................................................54 

Figure 3. Andersen Behavior Framework .................................................................................111 

Figure 4. Donabedian’s Quality Framework.............................................................................113 

Figure 5. Organizational Design Framework............................................................................116 

Figure 6. Schematic of relationships between situational characteristics and appropriate 

care coordination approaches...............................................................................117 

Figure 7. Relational Coordination Framework..........................................................................120 

Tables 

Table 1. Recent Medicare demonstration and pilot projects with care coordination 

 Elements.................................................................................................................20 

Table 2. Medicaid research projects with elements of care coordination..................................23 

Table 3. Example conferences in 2006 with care coordination themes.....................................27 

Table 4. Initial search strategies used to identify definitions of care coordination ...................33 

Table 5. Definitions for care coordination and related concepts ...............................................34 

Table 6. Components of care coordination ................................................................................47 

Table 7. Application of component list to well-described primary study..................................48 

Table 8. Elements common to care coordination definitions, and linkage to our working 

definition................................................................................................................49 

Table 9. Quality assessment of reviews with entire focus on care coordination .......................55 

Table 10. Selected characteristics of reviews with entire focus on care coordination.................59 

Table 11. Distribution of reviews with entire focus on care coordination by care 

coordination intervention.......................................................................................62 

Table 12. Quantitative outcomes reported by systematic reviews...............................................63 

Table 13. Reviews with entire focus on care coordination: cost results.....................................65 

Table 14a. Summary of reviews with entire focus on care coordination interventions: 

mental health..........................................................................................................79 
 xi

Table 14b. Summary of reviews with entire focus on care coordination interventions: 

heart failure ............................................................................................................83 

Table 14c. Summary of reviews with entire focus on care coordination interventions: 

diabetes ..................................................................................................................86 

Table 14d. Summary of reviews with entire focus on care coordination interventions: 

asthma ....................................................................................................................87 

Table 14e. Summary of reviews with entire focus on care coordination interventions: 

cancer .....................................................................................................................87 

Table 14f. Summary of reviews with entire focus on care coordination interventions: 

multiple clinical topics...........................................................................................88 

Table 14g. Summary of reviews with entire focus on care coordination interventions: 

pain management ...................................................................................................88 

Table 14h. Summary of reviews with entire focus on care coordination interventions: 

palliative care.........................................................................................................89 

Table 14i. Summary of reviews with entire focus on care coordination interventions: 

rheumatoid arthritis................................................................................................89 

Table 14j. Summary of reviews with entire focus on care coordination interventions: 

stroke......................................................................................................................90 

Table 14k. Summary of reviews with entire focus on care coordination interventions: 

no specific clinical topic ........................................................................................91 

Table 15. Summary of reviews with partial focus on care coordination interventions ...............96 

Table 16. Components described or evaluated by the systematic reviews ................................103 

Table 17. Operational processes ................................................................................................118 

Table 18. Summary of relationship of concepts across frameworks .........................................121 

Table 19. Instruments and measures related to care coordination mechanisms 

or patient/family perception of coordination .......................................................124 

Table 20. Suggested approaches for improving care coordination............................................134 

Appendixes 

Appendix A: Exact Search Strings 

Appendix B: Sample Data Abstraction Forms 

 Level One (Screening Title and Abstract) Form 

 Level Two (Full Text) Abstraction Form 

Appendix C: List of Excluded Reviews 

Appendix D: Technical Expert Panel and Peer Reviewers 

Appendices and Evidence Tables for this report are provided electronically at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/caregap/caregap.pdf. 

1 

Executive Summary 

Overview 

Many organizations and individuals are interested in care coordination, particularly as it 

relates to concerns about inefficiencies and suboptimal quality in the U.S. health care system. 

The Institute of Medicine (IOM) identified care coordination as one of 20 national priorities for 

action to improve quality along its six dimensions of making care safe, effective, patient 

centered, timely, efficient, and equitable. The burgeoning number of aging Americans with 

chronic illnesses and the increasing complexity of care create challenges to coordination 

experienced at every level—the patient, the clinical practice, and the system. Care coordination 

interventions are particularly attractive in that they have the potential to improve both efficiency 

and quality. 

This final Evidence Report in the series “Closing the Quality Gap” by the Stanford-UCSF 

Evidence-based Practice Center (EPC) addresses the topic of care coordination. The other 

reports in the series have focused on specific clinical conditions (e.g., hypertension, diabetes, 

asthma), which lend themselves to a standardized approach for identifying and evaluating 

primary studies of quality improvement strategies. For the cross-cutting (applicable to all areas 

of health care) and more loosely defined topic of care coordination, we did not attempt to 

synthesize the evidence from the primary literature. Instead, the Report describes our working 

definition of care coordination, summarizes some of the evidence about the effectiveness of care 

coordination interventions from systematic reviews, and presents relevant frameworks for the 

development and evaluation of future interventions. 

This approach may be useful to system-level policymakers, service-level decisionmakers, 

and patients. System-level policymakers (e.g., State Medicaid directors, Medicare officials, 

health plan managers) have responsibility for paying for health care services for large numbers of 

individuals (i.e., health plan enrollees, Medicare beneficiaries) and making decisions about how 

to coordinate care at a system level in ways that minimize their financial risks and maximize the 

health care received by their population of patients. Service-level decisionmakers (e.g., primary 

care doctors or managers of multi-specialty clinics) are involved in providing health care 

services to individual patients or a panel of patients, and therefore tackle care coordination at the 

service delivery level. Depending upon the particular local environment, they make decisions 

related to care coordination to maximize health care outcomes and use resources efficiently. 

Patients and their families are assuming increasingly active roles in health care decisionmaking 

and are navigating an increasingly complex health care system with consumer-driven health 

plans and other efforts to involve them more. The patient often experiences first-hand problems 

of coordination (e.g., missing medical records, duplicate testing, medical errors at transitions of 

care), and therefore may be just as interested as health care professionals in understanding care 

coordination. 

Key Questions 

The key questions addressed in this Report relate to four areas covered in each of the main 

Chapters of the report: 
2 

Ongoing Efforts in Care Coordination and Gaps in the 

Evidence (Chapter 2) 

• What aspects of care coordination are of greatest interest to healthcare decisionmakers? 

• What are the key gaps in the care coordination evidence base? 

Definitions of Care Coordination and Related Terms (Chapter 3) 

• What definitions exist for care coordination? 

• What definition could be formulated to apply to systematic reviews? 

Review of Systematic Reviews of Care Coordination 

Interventions (Chapter 4) 

• Which care coordination interventions have been evaluated by systematic reviews and how 

were they defined? 

• What is the evidence regarding the health benefits of these care coordination interventions as 

summarized in the systematic review(s)? In particular, is the effectiveness of care 

coordination interventions related to the setting in which care is being coordinated, the 

component of care being coordinated, or the type of disease or patients for whom care is 

being coordinated? 

• Have the costs of care coordination interventions been evaluated in any of these systematic 

reviews, and if so what is known? 

Conceptual Frameworks and Their Application to Evaluating Care 

Coordination Interventions (Chapter 5) 

• What concepts are important to understand and relate to each other for future evaluations of 

care coordination? What conceptual frameworks could be applied to support development 

and evaluation of strategies to improve care coordination? 

• What measures have been used to assess care coordination? 

• How do these frameworks relate to quality improvement strategies evaluated in the previous 

Closing the Quality Gap series reports? 

Methodology 

This project focused on two major activities: 1) assembly of background information about 

ongoing efforts in care coordination, definitions of care coordination and related terms (including 

components of care coordination) and conceptual frameworks presented in Chapters 2, 3 and 5, 

and a systematic review of evidence from systematic reviews on care coordination presented in 

Chapter 4. The first activity used searches for information that were not meant to be exhaustive, 

but rather illustrative. The second activity involved standard methods for a systematic review, 
3 

though the included articles were themselves systematic reviews as opposed to primary studies. 

The following sections summarize the basic approaches for each part of the project. 

Ongoing Efforts in Care Coordination and Gaps in the 

Evidence (Chapter 2) 

Background literature review, Internet searches, and personal contacts were used to find 

policy papers, conference brochures and information about ongoing care coordination programs, 

demonstration projects, and gaps in the evidence base. 

Definitions of Care Coordination and Related Terms (Chapter 3) 

Iterative searches of PubMed®, CINAHL® and Health and Psychological Instruments (HaPI) 

databases were supplemented with the information gathered for Chapter 2 to identify sources 

with definitions of care coordination and related terms. 

Review of Systematic Reviews of Care Coordination 

Interventions (Chapter 4) 

We searched MEDLINE® (through September 30, 2006), CINAHL®, Cochrane database of 

systematic reviews, American College of Physicians Journal Club, Database of Abstracts of 

Reviews of Effects, PsychInfo, Sociological Abstracts and Social Services Abstracts (these 

databases searched through November 15, 2006) for systematic reviews of care coordination 

interventions to improve quality of care provided to patients. 

Included Studies. English language systematic reviews of care coordination interventions, 

irrespective of clinical condition, patient population, or specific outcomes were included. 

Systematic reviews of interventions occurring solely in the hospital setting were excluded 

because findings would not be relevant to care across the continuum for those with chronic 

illnesses, a primary focus of the IOM’s prioritization of care coordination. Interventions where 

the only two participants were a clinician and the patient were excluded because these situations 

presumably have lower demands for coordination activities. Articles were included if they 

reported any evaluation metrics. 

Data Abstraction. From each of the included reviews, data were abstracted about whether 

the entire focus of the review was on care coordination or only a partial focus was on care 

coordination. For those reviews where the entire focus was on care coordination, abstracted data 

included: the research methodology used, setting of the care coordination intervention, terms and 

definitions used to describe the care coordination intervention, quality assessment variables, and 

the reported outcomes, including clinical outcomes, health services utilization, cost, costeffectiveness, and quality of life. For those reviews which only partially focused on care 

coordination, we abstracted data about the purpose of the review, the care coordination strategies 

included, and outcomes. 

Statistical Analysis. Results reported in the systematic reviews were reported separately and 

not synthesized quantitatively given the heterogeneity of the included articles. Narrative analysis 

was conducted. 
4 

Conceptual Frameworks and Their Application to Evaluating Care 

Coordination Interventions (Chapter 5) 

We used articles identified in the Chapter 3 search to identify literature describing conceptual 

frameworks and associated empirical evidence related to care coordination. We also reviewed 

the theoretical work developed in the behavioral, organizational, and health services research 

fields to select well-established frameworks relevant to care coordination with complementary 

concepts. We identified measures/scales related to care coordination and summarized their 

relationship to the frameworks. 

Findings 

Summary Answers to the Key Questions 

Research Question 1: What Aspects of Care Coordination Are of Greatest Interest to 

Healthcare Decisionmakers? Health professionals raised concerns about the lack of a care 

coordination definition and conceptual model. They considered these deficiencies as barriers to 

effectively evaluating and assessing care coordination efforts. They also frequently expressed a 

need for additional evidence regarding the influence of care coordination programs on health, 

cost, and satisfaction outcomes. Many decisionmakers simply wanted to know if care 

coordination actually worked, and, if so, how it affects costs. Furthermore, those with 

responsibility for managing healthcare sought answers for what approaches to care coordination 

were likely to work, under which circumstances (e.g., by disease, setting, geographical region, 

payor, etc.), and for which patient populations. Finally, decisionmakers were keenly interested 

in the development of measures and approaches to examine the effectiveness and quality of care 

coordination interventions. 

Research Question 2: What Are the Key Gaps in the Care Coordination Evidence 

Base? The care coordination field would benefit from consensus definitions, conceptual models, 

and measures of care coordination processes. However, the dearth of evidence surrounding the 

efficacy and cost-effectiveness of various care coordination programs are also pressing issues 

facing decisionmakers. They want practical answers about how to implement effective and 

efficient care coordination, and yet the field is only just emerging as an area of concerted study 

from a conceptual as well as a pragmatic perspective. 

Research Question 3: What Definitions Exist for Care Coordination? The term, “care 

coordination,” is cited often in the health services literature, but is infrequently explicitly 

defined. We identified more than 40 definitions of coordination and they pertain to a diverse set 

of patient populations, healthcare scenarios, and organizational situations. While definitions 

vary depending on their purpose and audience, five common elements of care coordination were 

identified from our review of definitions and studies related to coordination: 

1. Numerous participants (including the patient) are typically involved in care coordination; 

2. Coordination is necessary when participants are dependent upon each other to carry out 

disparate activities in a patient’s care; 

3. In order to carry out these activities in a coordinated way, each participant needs adequate 

knowledge about their own and others’ roles and available resources; 
5 

4. In order to manage all required patient care activities, participants rely on exchange of 

information; and 

5. Integration of care activities has the goal of facilitating appropriate delivery of health care 

services. 

Research Question 4: What Definition Could be Formulated To Apply to Systematic 

Reviews? We combined the common elements from many definitions to develop our following 

working definition, which we used to guide our review of systematic reviews on care 

coordination: 

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 marshalling 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. 

Our working definition is purposely broad enough to include interventions that are 

sometimes defined by their own related terminology (e.g., disease management, case 

management, teamwork, collaboration, Wagner’s Chronic Care Model and extensions). It is also 

applicable to programs, such as the Medicare demonstration projects to improve care for those 

with chronic illness. The objective of these interventions and programs is to improve quality of 

care, in part or in total by enhancing coordination between participants for the benefit of the 

patient (improved outcomes) and the system (reduced costs). 

We also developed a list of components of care coordination (Table A) to support a more 

granular analysis of interventions. The components are separated into essential care tasks (e.g., 

identify participants and their roles), their associated coordination activities (e.g., coordinate 

among care plans), and common features of interventions to support coordination activities (e.g., 

standardized protocol, multidisciplinary team). The list draws extensively from components 

described by clinical professional organizations, recent consensus development efforts by the 

National Quality Forum, and intervention evaluators. 

Research Question 5: Which Care Coordination Interventions Have Been Evaluated by 

Systematic Reviewers and How Were They Defined? Among our included reviews, we 

identified various care coordination interventions that have been evaluated. The terms used to 

define the care coordination strategies were highly heterogeneous. The 43 individual reviews 

that focused entirely on care coordination referred to 20 different care coordination interventions. 

The most common strategy evaluated the use of multidisciplinary teams involving two or more 

providers from different specialties providing care to a group of patients (15 reviews); the terms 

applied to this strategy included multidisciplinary teams, team coordination, assertive community 

treatment, collaborative care, integrated programs, and shared care. The next most common 

strategy evaluated was disease management (10 reviews). It was defined variably or not at all in 

the included reviews and there did not appear to be a consensus about the components that 

should be included in a disease management program; however, the intent of all the disease 

management programs reviewed was to improve the coordination of patient care, provide 

support to patients, and improve patient outcomes. Finally, nine reviews assessed the role of 

case management (also referred to as care management) which typically involves the assignment 
6 

Table A. Components of care coordination 

Component Comparable Domains Noted by Others 

ESSENTIAL CARE TASKS and Associated Coordination Activity 

ASSESS PATIENT 

Determine Likely Coordination Challenges

Initial Assessment (M) 

DEVELOP CARE PLAN

Plan for Coordination Challenges and Organize Separate Care Plans

Proactive Plan of Care and Follow-up 

(NQF) 

Problem Identification and Care Planning 

(M) 

IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES 

Specify Who Is Primarily Responsible For Coordination

Healthcare ‘home’ – source of usual care 

selected by patient (NQF) 

Program Staffing (M) 

Provider Practice (M) 

COMMUNICATE TO PATIENTS AND ALL OTHER 

PARTICIPANTS 

Ensure Information Exchange Across Care Interfaces

Communication-available to all team 

members, including patients and family 

(NQF) 

Communication (M) 

EXECUTE CARE PLAN 

Implement Coordination Interventions

Service Arranging (M) 

MONITOR AND ADJUST CARE 

Monitor For And Address Coordination Failures

Ongoing Monitoring (M) 

EVALUATE HEALTH OUTCOMES 

Identify Coordination Problems That Impact Outcomes

Quality Management/ Outcomes 

Measurement (M) 

COMMON FEATURES OF INTERVENTIONS TO SUPPORT COORDINATION ACTIVITIES and 

Examples

INFORMATION SYSTEMS 

Electronic medical record; Personal health record; Continuity of care 

record, Decision support ; Used for population identification for 

intervention

Information systems - the use of 

standardized, integrated electronic 

information (NQF) 

Information Technology and Electronic 

Records (M) 

TOOLS 

Standard protocols, Evidence-based guidelines, Self-management 

program, Clinician education on coordination skills, Routine 

reporting/feedback

Patient Education (M) 

TECHNIQUES TO MITIGATE INTERFACE ISSUES 

Multidisciplinary teams for specialty and primary care interface; 

Case manager or patient navigators to network and connect between 

medical and social services; Collaborative practice model to connect 

different setting or levels of care; Medical home model to support 

information exchange at interfaces

Transitions/Handoffs - transitions between 

settings of care (NQF) 

SYSTEM RE-DESIGN 

Paying clinicians for time spent coordinating care; Changes that 

reduce access barriers including system fragmentation, patient 

financial barriers - lack of insurance, underinsurance, physical 

barriers - distance from treatment facilities

Environmental Level (e.g., consideration 

of alignment of incentives); Health care 

system reorganization (IOM) 

NQF = National Quality Forum domain; M = Mathematica evaluation area; IOM = Factor noted in report on “Priority Areas for 

National Action” 

of a single person (case manager or “key worker”, so named in one study) who coordinates all 

aspects of a patient’s care (e.g., providing information to multiple providers, seeing that the 

patient receives services in a timely manner etc.). The qualifications and exact duties of case 

managers were poorly described in most reviews. Other strategies evaluated were integration of 
7 

care (three reviews), and interprofessional education, defined as the provision of training and 

education to professionals from different health and social areas, who learn together interactively 

(three reviews). 

Research Question 6: What is the Evidence Regarding the Health Benefits of These 

Care Coordination Interventions as Summarized in the Systematic Review(s)? In 

Particular, is the Effectiveness of Care Coordination Interventions Related to the Setting in 

Which Care is Being Coordinated, the Component of Care Being Coordinated, or the Type 

of Disease or Patients for Whom Care is Being Coordinated? Among the 43 reviews that 

focused on care coordination interventions, and an additional 32 that included care coordination 

among other quality improvement approaches, the most common conditions targeted were 

mental health conditions (28 reviews), heart failure (14 reviews) and diabetes (seven reviews). 

Eleven reviews were not specific to any condition. Overall, the reviews reported a positive 

effect of the care coordination strategies on the outcomes studied, regardless of clinical topic. 

Multiple systematic reviews provided evidence of patient benefit resulting from multidisciplinary 

teams, disease management, and case management. Multidisciplinary team interventions 

improved service continuity for severely mentally ill patients (two reviews); reduced mortality 

and hospital admissions in heart failure patients (two reviews); reduced symptoms for terminally 

ill patients (one review); and reduced mortality and dependency in stroke patients (one review). 

Disease management programs reported improved depression severity and adherence to 

treatment in patients with mental illness (one review); reduced mortality and hospital admissions 

in heart failure patients (two reviews); and reduced glycated hemoglobin (one review) and 

improved glycemic control (one review) in patients with diabetes. Case management as a care 

coordination strategy appeared to improve re-hospitalization rates in patients with mental health 

problems (one review) and improved glycemic control in patients with diabetes (one review). 

While these and other care coordination interventions (e.g., integrated care, shared care, 

organized clinic) have been reported in systematic reviews covering other clinical areas such as 

rheumatoid arthritis, pain management, asthma and cancer, there is insufficient evidence to draw 

firm conclusions in these other instances. 

Setting of Care. Interventions were conducted across different settings (home, community, 

outpatient clinic), with half of the reviews conducting interventions across multiple settings, an 

interface commonly noted as challenging for coordination of care. One review on heart failure 

reported that interventions with a home-based component or telephone follow-up were more 

effective than those based in the hospital or clinic, but there is little evidence to examine the 

effect of setting on the effectiveness of care coordination interventions. Furthermore, there was 

also insufficient evidence to determine the relative effectiveness of any particular care 

coordination intervention compared to others in improving patient outcomes across care 

boundaries. 

Components of Care Coordination. Using a list of essential tasks of care for a patient, 

associated care coordination activities, and features to support the activities, we reviewed 15 

recent systematic reviews to assess if the reviews provided any information on specific 

components of the care coordination intervention; 13 of these provided limited information. The 

descriptions of interventions presented in systematic reviews generally do not provide adequate 

information for complete categorization into components. The current evidence base does not 

support a granular, component-level analysis from systematic reviews. 

Patient Population. Among our included systematic reviews, care coordination interventions 

were most frequently targeted at patients with mental health problems (multidisciplinary teams 
8 

and case management being the main interventions evaluated in this population); heart failure 

and diabetes were the next most frequently studied conditions. The main interventions evaluated 

for heart failure were multidisciplinary teams and disease management and while the reviews 

were consistent in reporting improved outcomes associated with both these interventions, there 

was considerable overlap of the included studies across the reviews studying patients with heart 

failure. Care coordination interventions were also evaluated among a diverse group of clinical 

conditions (diabetes, asthma, heart condition, stroke, rheumatoid arthritis, cancer, pain 

management). Most of the reviews reported improved outcomes for each strategy; however, 

there was insufficient evidence that one particular strategy was more effective than others in 

improving outcomes. 

Most of the included systematic reviews evaluated care coordination interventions in adults 

in the general population of patients from primary care or hospital settings. Eight of the reviews 

evaluated interventions among the elderly, a vulnerable group more likely to have poorly 

coordinated care. The findings from these reviews suggest that care coordination strategies may 

improve outcomes among elderly patients (specifically by decreasing hospital admissions); 

however, the heterogeneity of the included strategies do not permit any further synthesis that 

would allow us to assess the effectiveness of one particular strategy over another. 

Summary. The overall quality of the included systematic reviews was very good, with most 

reviews providing detailed search terms, inclusion/exclusion criteria and appropriate synthesis of 

their included articles. Therefore, the generally positive findings for many of the interventions 

are encouraging, and offer health professionals and system level decisionmakers with a range of 

options to test in their own environments. 

Research Question 7: Have the Costs of Care Coordination Interventions Been 

Evaluated in Any of These Systematic Reviews, and if so What is Known? Costs were 

evaluated in approximately half of the included reviews that focused solely on care coordination; 

however, only one of the reviews reported findings on the cost-effectiveness/cost-benefit of the 

care coordination intervention. The evidence from this review suggests that comprehensive 

disease management programs are cost-effective for improving outcomes in patients with 

depression. The remaining reviews provided some cost estimates of the interventions evaluated; 

however, the evidence was insufficient to allow for any definitive conclusions regarding the 

costs and benefits of the care coordination interventions evaluated. Some studies reported 

increased utilization of services for the coordination intervention group. 

Research Question 8: What Concepts are Important To Understand and Relate to 

Each Other for Evaluations of Care Coordination? What Conceptual Frameworks Could 

be Applied To Support Development and Evaluation of Strategies To Improve Care 

Coordination? We identified four well-established frameworks that complement each other in 

terms of developing and studying care coordination interventions. Taken together, the 

frameworks include a dozen concepts generally fitting into one of three domains: baseline 

assessment of the specific patient care situation, coordination mechanisms, and outcomes of care. 

These frameworks provide evaluators of new interventions with a guide to exploring the 

possible relationships and connections between an intervention and patient outcomes. 

Developers and evaluators of interventions to improve coordination need to ask: 
9 

• What are the coordination needs related to patient care? 

• Who are the participants in care, and how are they dependent on each other for a given care 

situation)? 

• What are the factors already in place that may facilitate care coordination (e.g., personnel 

resources, information systems)? How does the intervention interact with or involve these 

factors? 

• What are the factors that influence the motivation of those involved in coordination (e.g., 

attitudes, incentives)? 

• How is the intervention expected to change the key coordination processes of 1) getting the 

necessary information across interfaces, such as different settings of care (i.e., “informational 

exchange” from one theory), and 2) establishing an understanding of the relationship of one 

individual’s work to the overall goals and to that of others involved in patient care (i.e., 

“relational awareness” from another theory)? 

• How are the interactions of these factors and coordination processes expected to affect 

clinical processes and patient outcomes (e.g., what is the hypothesis about why the 

intervention will work)? 

Research Question 9: What Measures Have Been Used To Assess Care Coordination? 

Studies of care coordination have evaluated patient outcomes, including changes in mortality, 

symptoms, unemployment, staying connected to services, and adherence to medication. Cost 

and utilization outcomes, including hospitalizations, emergency department visits, and clinic 

visits were included in a number of studies. Also, patient and family satisfaction were reported 

in some instances. 

We also separately searched the literature for instrument development related to care 

coordination, and found 20 instruments and approaches. About half of the instruments are 

targeted at patient and family members, and ask about perceptions of care, including items about 

coordination (e.g., “treatment was planned with appropriate considerations of previous course of 

the disease”,*

 “told me which nurse was primarily responsible for coordinating my care.”** Two 

of the instruments derive their data from chart reviews to assess the information exchanged 

between physicians. Seven instruments survey physicians or members of a defined care team to 

assess collaboration and teamwork processes and performance. Two instruments evaluate 

resources and structures (e.g., community linkages) that support care coordination. One of these 

instruments is for systems that care for adults with chronic illness, and the other is for primary 

care practices that have adopted a “medical home” approach to pediatric care. 

The measurement field related to care coordination is in the early phases of its development. 

It is as yet unclear what approach or combination of approaches to measurement will adequately 

capture the processes driving an intervention’s effect, particularly outside well-defined care 

settings, where the challenges for coordination are most salient to patients and families. 

 

*

 Morita T, Hirai K, Sakaguchi Y, et al. J Pain Symptom Manage. 2004 

** Radwin L, Alster K, Rubin KM. Oncol Nurs Forum. 2003 
10 

Research Question 10: How do These Frameworks Relate to Quality Improvement 

Strategies Evaluated in the Previous Closing the Quality Gap Series Reports? The IOM 

Priorities Report highlighted care coordination as a topic that cut across other specific clinical 

areas that were priorities for national action (e.g., hypertension, diabetes, asthma, etc.) that were 

covered in previous reports from our Closing the Quality Gap series. The quality improvement 

strategies evaluated in these previous reports—namely patient education, self management, 

provider education, provider reminders, audit and feedback, relay of clinical data, organizational 

change, financial and regulatory incentives—are relevant to care coordination. While most do 

not target coordination of care, these strategies share the objective of improving care through 

changing patient, provider or organizational behavior, and can be viewed through the Andersen 

behavior framework, which highlights the importance of “predisposing” or “enabling” factors 

(e.g., financial incentives or provider education). In addition, many of the strategies relate to two 

other conceptual frameworks described in the report–the organizational design and relational 

coordination frameworks (e.g., provider reminders as an operational process that improves 

information transfer; patient education and self-management aimed at enhancing communication 

between patient and physician, which in turn might result in more coordinated care). Finally, 

many of the quality improvement interventions categorized as organizational change strategies 

are the same as those reviewed here as care coordination interventions (e.g., case management, 

disease management, creation of multidisciplinary teams). These reports were not included in 

our review, as they are all part of the Closing the Quality Gap series. 

Discussion 

The concept of care coordination is extremely broad, making it tempting to focus on specific 

terms or types of approaches—such as disease management, case management, teamwork, or 

Wagner’s Chronic Care Model—in order to provide an in-depth analysis on a limited area. 

However, the choice of approaches to coordinating care is likely to be tied to the specific 

circumstances and constraints of a given setting or patient population. Therefore, this Evidence 

Report aimed to produce a working definition of care coordination; a broad overview of potential 

care coordination interventions from a systematic review literature; and a description of ongoing 

programs, available evidence on their effectiveness, and several frameworks for thinking about 

key variables and measures relevant to studying care coordination in the future. The Report thus 

represents a starting point for understanding care coordination and its potential to improve 

patient outcomes and reduce health care costs. It concludes with specific actions that patients, 

providers and system-level decisionmakers might take now. Much further work is needed, 

however, and the Report also concludes with recommendations for future conceptual and 

evaluation research. 
Technical Review 

13 

Chapter 1. Introduction 

“Like a sailing ship needs a navigator to avoid the 

rocks, patients need navigation to get all the way 

through the medical system as quickly as possible... We 

put Patient Navigators in place in Harlem Hospital in 

1994, and we have found them to be very effective at 

getting people treated. We don’t lose patients 

anymore.” Dr. Harold P. Freeman*

The U.S. health care delivery system suffers from pervasive deficiencies and remarkable 

variation in patient safety and healthcare quality.2-5 While numerous factors may explain 

continued poor performance and variation, one commonly accepted belief is that improvements 

in care coordination can help reduce fragmentation of patient care, lead to better quality, and 

potentially, lower costs. In Priority Areas for National Action: Transforming Health Care 

Quality, the Institute of Medicine (IOM) suggested that improvements in care coordination could 

result in significant benefits “across the continuum of care across the life span,” and called for 

national action on this “cross-cutting” topic.6 

Clinical vignettes of patients receiving care in a well-coordinated system provide a striking 

contrast to those of patients navigating the more typical uncoordinated system.2, 7 Patients with 

complex health care needs, their families, and their providers often must traverse numerous 

professional, geographical, information system, and organizational boundaries to ensure that 

necessary care activities are performed adequately.8-13 Failing to overcome these barriers may 

disrupt the flow of critical information and heighten patient vulnerability to medical errors; 

duplication, omission, or delay of services; and poor outcomes. However, the evidence base 

connecting care coordination to its potential positive effects is sparse, and the definitions and key 

concepts underlying the topic are unresolved.7

1A. Report Scope and Organization 

This report is the sixth in the series “Closing the Quality Gap” by our Stanford-UCSF 

Evidence-based Practice Center (EPC), and addresses the topic of care coordination. The other 

reports in the series have focused on specific clinical conditions (e.g., hypertension, diabetes, 

asthma), which lend themselves to a standardized approach for identifying and evaluating 

primary studies of quality improvement strategies. However, for the broader and more 

ambiguous topic of care coordination, our objective was to identify and fill in some of the major 

gaps in the evidence regarding the key definitions and concepts of care coordination and provide 

an overview of the effectiveness of care coordination interventions on the processes and 

outcomes of care for outpatients, typically for those with chronic medical conditions. We did not 

aim to identify and present all of the primary evidence related to this broad topic. Instead, we set 

out to provide an overview of ongoing efforts in health care coordination, summarize some of the 

evidence about the effectiveness of care coordination interventions, and present relevant 

 

*

 Quote from polo.com interview with Dr. Harold P. Freeman, past President of the American Cancer Society, 

explaining the need for patient navigation in a fragmented system with barriers to coordinated delivery of care, 

accessible to all people.1
14 

frameworks for the development and evaluation of future interventions. This background and 

approach may be useful to a variety of decisionmakers: for example, designers of interventions 

who need to make decisions about what to include in a package of interventions aimed at 

improving care coordination, evaluators of interventions who need to assess comparative 

effectiveness of different approaches to improving coordination, and purchasers of interventions 

to reduce the adverse consequences of fragmentation of health care services. 

As a result, this report is organized differently than the others in the series. We first describe 

ongoing efforts in care coordination and describe the relevant information needed by 

decisionmakers involved in improving care coordination (Chapter 2). We synthesized this 

information from personal contacts with professionals currently leading care coordination efforts 

and Internet searches—it was not intended to be exhaustive. Second, we describe contemporary 

definitions of care coordination and related concepts from which we developed a working 

definition for use in identifying relevant evidence (Chapter 3). Third, we present a review of 

systematic reviews of the effects of care coordination interventions for outpatients (and 

inpatients whose care was not solely limited to that setting) who, in most cases, have chronic 

medical conditions (Chapter 4). Fourth, we describe conceptual frameworks from different fields 

that explore care coordination needs, approaches to coordinating care, and patient outcomes 

(Chapter 5). For Chapters 3, 4, and 5, we performed extensive literature searches, although only 

the review presented in Chapter 4 is completely systematic since its purpose is to synthesize 

information from evaluations of care coordination interventions. Finally, we conclude with a 

discussion of the future research required to further understand and benefit from care 

coordination efforts (Chapter 6). 

1B. Key Research Questions 

The key questions addressed in each of the chapters of this report are listed here and 

summarized at the end of each chapter: 

Background: Ongoing Efforts in Care Coordination and Gaps in the 

Evidence (Chapter 2) 

Research Question 1: What aspects of care coordination are of greatest interest to 

healthcare decisionmakers? 

Research Question 2: What are the key gaps in the care coordination evidence base? 

Definitions of Care Coordination and Related Terms (Chapter 3) 

Research Question 3: What definitions exist for care coordination? 

Research Question 4: What definition could be formulated to apply to systematic reviews? 
15 

Review of Systematic Reviews of Care Coordination 

Interventions (Chapter 4) 

Research Question 5: Which care coordination interventions have been evaluated by 

systematic reviewers and how were they defined? 

Research Question 6: What is the evidence regarding the health benefits of these care 

coordination interventions as summarized in the systematic review(s)? In particular, is the 

effectiveness of care coordination interventions related to the setting in which care is being 

coordinated, the component of care being coordinated, or the type of disease or patients for 

whom care is being coordinated? 

Research Question 7: Have the costs of care coordination interventions been evaluated in 

any of these systematic reviews, and if so what is known? 

Conceptual Frameworks and Their Application to Evaluating Care 

Coordination Interventions (Chapter 5) 

 

Research Question 8: What concepts are important to understand and relate to each other 

for evaluations of care coordination? What conceptual frameworks could be applied to support 

development and evaluation of strategies to improve care coordination? 

Research Question 9: What measures have been used to assess care coordination? 

Research Question 10: How do these frameworks relate to quality improvement strategies 

evaluated in the previous Closing the Quality Gap series reports? 

1C. Peer Review 

A draft of the Evidence Report was sent to a panel of 21 experts in quality improvement, 

researchers in the area of care coordination, and other professionals with an interest in care 

coordination (Appendix D*). We compiled their comments and made appropriate revisions to 

the final Report. The revision included updating the systematic review search, which resulted in 

22 additional reviews analyzed. 

 

*

 Appendixes cited in this report are provided electronically at http://www.ahrq.gov/clinic/tp/caregaptp.htm 

17 

Chapter 2. Background: Ongoing Efforts in Care 

Coordination and Gaps in the Evidence 

Given the fragmented nature of the U.S. healthcare system, healthcare providers have 

increasingly implemented programs aimed at coordinating the care patients receive. Although 

these programs vary widely in structure and style, the primary goals of care coordination 

programs—to improve disease outcomes while containing overall healthcare costs—tend to be 

consistent across organizations. Historically, most care coordination programs have targeted 

patients with chronic conditions, which are costly, especially if managed poorly. According to a 

2004 Partnership for Solutions report, 48% of the U.S. population has one or more chronic 

conditions; all their care represents 83% of total healthcare spending.14 Patients with chronic 

conditions visit their health care providers, fill prescriptions, and are hospitalized more often 

than the general population.14 Furthermore, patients with chronic conditions are more likely to 

experience poorly coordinated care, which can lead to adverse drug interactions, unnecessary or 

duplicate tests or procedures, conflicting information from multiple providers, and increased 

health care costs.14

These issues have challenged care providers, health system designer, policymakers and the 

research community for many years, though pressures have mounted in recent years with 

changing demography and patterns of illness (from more acute orientation to chronic care). 

Traditionally, coordination interventions follow from several perspectives: medical versus social; 

short-term episodic or acute care versus chronic and long term care; and various points of access 

to the patient (e.g., patient targeting to find those in need of high intensity services, managed care 

organization, or physician office practice). In the 1980’s the National Long term Care 

Demonstration Project, a large scale randomized control trial of community care which tested 

channeling patients at risk of deteriorating and needing nursing home care into enriched models 

of community care based on case management and varying levels of authority and financial 

incentives.15 This project, commonly referred to as “Channeling” found that risk prediction was 

problematic in some cases, there was no benefit in terms of cost or clinical outcomes, and 

increased caregiver satisfaction.16, 17 This project exemplifies the need to test complex 

interventions because findings are not always as expected. This study as well as other prominent 

work in the 1980’s and 90’s (especially the Social Health Maintenance Organization (S/HMO) 

Projects18, 19 and the Program of All-Inclusive Care for the Elderly (PACE20, 21)) also provided 

important lessons about linking medical and social models flexibly in order to achieve care 

coordination. Although the temptation in studying care coordination is to restrict the scope, 

historical experience demonstrates a need to consider interactions between separate systems of 

care (e.g., acute, community, long-term). 

In the more recent past, care coordination programs initially gained a stronghold in the 

private sector, where managed care organizations, commercial vendors, academic medical 

centers, and private health insurers sought to implement coordinating mechanisms aimed at 

controlling costs, improving disease outcomes, quality of care, and patient satisfaction.22 Public 

sector programs, such as Medicare and Medicaid, followed suit with a series of congressionally 

mandated demonstration and pilot projects to test the efficacy of care coordination and disease 

management programs. 
18 

The goal of this chapter is to provide an overview of ongoing efforts in care coordination and 

key gaps in the evidence about the effectiveness of care coordination efforts. In the sections that 

follow, we first describe ongoing care coordination programs and related activities. Then, we 

present key questions related to the mechanisms and aims of care coordination of concern to 

health professionals. Finally, we highlight key gaps in the care coordination evidence-base. 

Our approach to collecting the information presented in this chapter relied on background 

literature searches for policy papers, Internet searches using care coordination and related 

terminology for ongoing care coordination programs and demonstration projects, searches for 

conference brochures, and personal contacts with professionals currently leading care 

coordination efforts. This search was not intended to be exhaustive or fully systematic. 

2A. Care Coordination Vendors 

In the past decade, there has been a dramatic increase in the number of commercial 

companies selling care coordination services to healthcare providers. Many of these refer to 

their services as disease management or care management. The revenue associated with the sale 

of disease management services has increased more than ten-fold, from $78 million in 1997 to 

$1.2 billion in 2005.23 Initially, disease management vendors tended to focus on a small number 

of chronic conditions, but more recently some of the larger companies have extended their 

services to cover more than 120 conditions.23 These trends relate to outsourced disease 

management, and thus do not necessarily reflect disease management practices set up internally 

by some health care providers. The market has also expanded in terms of the types of providers 

of these services, including health plans, pharmaceutical companies, pharmacy benefit 

management companies, disease management companies, and even health and information 

companies selling specific disease management tools (e.g., physician alerts, 24-hour call centers, 

educational material, care monitoring software, etc.). While the industry has traditionally 

focused on physical health conditions, the public sector demands for integration and efficient 

resource use for mental health and substance abuse disorders have encouraged new roles for 

managed behavioral health organizations.24

Perhaps one of the biggest issues facing care coordination vendors, and the field at large, is 

how to best measure and evaluate the effectiveness of their programs. Evaluators are interested 

linking specific components of care coordination and intensity of intervention (e.g., number of 

contacts, caseloads) to outcomes. Organizations, such as the Disease Management Association 

of America (DMAA), are currently working to develop standardized disease and care 

management measures. Other groups, such as the Joint Commission on Accreditation of 

Healthcare Organizations (JCAHO), the Utilization Review Accreditation Commission (URAC), 

and the National Committee for Quality Assurance (NCQA) have initiated accreditation and 

certification programs for disease management programs. Efforts to evaluate effectiveness and 

efficiency are widespread, although the evidence from the peer-reviewed literature describing 

these efforts is mixed.25 In general, vendors report positive return on investment (ROI) numbers, 

though buyers have expressed concern about biased methods and a lack of comparability across 

ROI analyses.26-28 Observers of the field have also voiced concerns about relying on potentially 

out-of-date findings from projects conducted in a dynamic health plan environment.29, 30
19 

2B. Purchasers and Developers of Care 

Coordination Programs 

Medicare 

Twenty-three percent of Medicare beneficiaries with five or more chronic conditions account 

for 68% of total Medicare spending.31 The care these individuals receive is often fragmented 

across settings and providers, with many providers failing to follow evidence-based guidelines 

and with patients not well versed in self-care management strategies.22 This lack of coordination 

often results in poor clinical outcomes, repeated hospitalizations, excessive utilization of 

prescription drugs, medical errors, dissatisfaction with care, and higher costs to the Medicare 

program.32, 33

In response to this association between poorly coordinated care among Medicare 

beneficiaries with multiple chronic medical conditions and poorer outcomes of care, the 

Balanced Budget Act of 1997 mandated a coordinated care demonstration study for chronically 

ill fee-for-service Medicare beneficiaries.32 To determine the best practices in coordinated care 

and assess how best to structure the demonstration project, the Centers for Medicare & Medicaid 

Services (CMS) commissioned a report from Mathematica Policy Research, Inc. (Princeton, New 

Jersey) that examined existing care coordination schemes and proposed design options for future 

demonstration projects. Their 2000 report, entitled, “Best Practices in Coordinated Care,”32

made the following five recommendations: 

1. “Programs should follow the three steps: Assess and Plan, Implement and Deliver, and 

Reassess and Readjust for all enrolled patients; 

2. Programs should have express goals of prevention of health problems and crises, and of early 

problem detection and intervention; 

3. Disease-specific programs should incorporate national evidence-based or consensus-based 

guidelines into their interventions; 

4. Care coordinators should be nurses with at least a bachelor’s degree in nursing; and 

5. Programs should have significant experience in care coordination and should have evidence 

of having reduced hospital use or total medical costs.”32 

Since the publication of this report, CMS has funded a number of care coordination and 

disease management demonstration projects designed to improve health outcomes without 

increasing costs. These projects have typically emanated from legislative mandates. For 

example, Congress established the Chronic Care Improvement Program (since termed Medicare 

Health Support) in the Medicare Prescription Drug, Improvement, and Modernization Act 

(MMA) of 2003 (Public Law 108-173; section 721)34, 35 to test new incentives and approaches 

for improving care coordination for elders with high cost complex and chronic illnesses. We 

have provided a brief description of several Medicare care coordination demonstration projects 

in Table 1 and direct the interested reader to the Medicare Demonstration Projects Evaluation 

Web Site36 for additional information and future updates.
Table 1. Recent Medicare demonstration and pilot projects with care coordination elements 

Demonstration 

Project 

Description Project Goals Sta

Medicare Health Support: initially called Chronic Care Improvement Program Demonstration37

8 organizations called Medicare Health Support Organizations (MHSO), will each manage the care of about 20,000 traditional fee-for-service Medicare beneficiaries with congestive heart failure and/or diabetes among their chronic conditions. Programs focus on improving health outcomes through a variety of coordination approaches (care plans, patient monitoring, disease management, case management, information technologies, collaborations with physicians, etc.) for prospectively identified target populations where care has typically been fragmented. MHSO payments tied to performance. Program is voluntary for beneficiaries, with no change in where they seek care. 

-Improve quality of life by helping participants avoid complications -Increase adherence to evidence-based care -Reduce unnecessary hospital stays and emergency room visits 

-Organizations selected in starting at various times fJanuary 2006 -Results not reported yet -3-year operation and evaeach program -Additional information: http://www.cms.hhs.gov/.pdf 

Care Management for High-Cost Beneficiaries Demonstration38, 

39

Six organizations over a 3-year period will evaluate various care management models for high-cost beneficiaries in the traditional Medicare fee-for-service program. Approaches emphasize information technology and collaboration between physicians and specialists to enhance communication of clinical information. 

-Increase adherence to evidence-based care -Reduce unnecessary hospital and emergency room visits -Help participants avoid complications 

-Scheduled to begin late 2-Results not reported yet -Additional information: http://www.cms.hhs.gov/wnloads/CMHCB_Gener

Medicare Benefits Improvement and Protection Act (BIPA) Demonstration Project40

In Texas, Louisiana, California and Arizona up to 30,000 

beneficiaries with diagnosed advanced-stage congestive heart failure, diabetes, or coronary disease will be randomized to receive disease management services and a comprehensive prescription drug benefit, or usual care. 

-Lower total costs -Improve health outcomes 

-3-year project started in -Results not reported yet -Additional information: http://www.cms.hhs.gov/wnloads/BIPAADM_Fac

20
Table 1. Recent Medicare demonstration and pilot projects with care coordination elements (continued) 

Demonstration 

Project 

Description Project Goals Sta

Medicare Coordinated Care Demonstration41

15 sites were selected to test a variety of care coordination schemes in urban and rural settings. The selected projects include a mix of case and disease management models targeting complex chronic illnesses, including sites focused on congestive heart failure, coronary artery disease, and cancer. 

-Reduce the number of hospitalizations -Improve health status -Reduce health care costs 

-Site selection announced -Initial report with prelim200442

-Final report due not avai-Additional information: http://www.cms.hhs.gov/media/press/release.asp?C

Physician Group Practice Demonstration43

During this 3 year demonstration, Medicare will provide financial incentives for 10 physician groups to improve patient outcomes at no additional cost through care coordination schemes. These include implementing disease and/or case management services; enhancing access to primary care physicians, geriatricians, and nursing staff; and using electronic medical records, disease registries, and evidence-based guidelines. While the demonstration requires large groups of physicians (200 or more), the arrangements between these physicians varies, including one network of small office-based physician practices. 

-Prevent unnecessary hospitalizations and procedures -Improve quality of care -Prevent complications - Reduce health care costs 

-Began 2005 -Final results not reported -Conference report on ear“high-cost/high-risk patieprograms... target patienchronic diseases. Transiti[enhance] hospital and emplanning.44

-Additional information: http://www.cms.hhs.gov/wnloads/PGP_Fact_Shee

21
22 

Medicare has implemented a variety of care coordination projects that differ in design and 

are currently in varying stages of implementation. At the time of publication of this report, 

however, comprehensive and finalized results of these demonstrations were not available. 

Similarly, specific details about financial arrangements and actual implementation experience are 

not generally available. Within the next one to three years additional information about the 

demonstration experiences, cost effectiveness, patient and provider satisfaction, and general 

effectiveness of care coordination programs within the Medicare system should be available. 

State Medicaid Programs 

Medicaid beneficiaries with chronic conditions account for more than three-quarters of 

current Medicaid spending.45 State Medicaid programs have increasingly utilized care 

coordination programs in an effort to contain costs and better meet the needs of beneficiaries. 

The focus of most Medicaid programs, which have been implemented through vendors, has been 

on patient self-management support and nurse case-management. 

According to a 2004 Kaiser Family Foundation survey of Medicaid directors, states have 

increasingly implemented disease management programs to contain costs for patients with 

chronic or disabling conditions.46 Between 2002 and 2005, 42 states began a disease or case 

management program.46 Additionally, state Medicaid programs have trended towards broader 

disease management programs that are not defined by specific conditions to help manage 

patients with multiple chronic and complex conditions.47 The key findings of the survey of 

Medicaid directors’ impressions indicate that disease management programs appear to lead to 

cost savings, and that carefully designed disease management programs, which go beyond 

teaching self-care principles to address the underlying infrastructure of care, have potential for 

the most success.47 

Across the U.S., state Medicaid programs vary in terms of their approaches to care 

coordination. For example, the 2004 report by the National Pharmaceutical Council identified 

four methods of delivering disease management to Medicaid recipients with asthma: 

1. “Medicaid health outcomes partnerships are usually applied to an existing fee-for service 

primary care case management program. Medicaid programs focus on high-priority diseases, 

offering a number of support systems to help existing Medicaid providers better serve the 

patients assigned to them; 

2. Disease management organizations are outside contractors who are retained by the state to 

address particular diseases, either by supplementing existing Medicaid providers and their 

case management activities or by taking over responsibility for targeted patients; 

3. Pay for performance approaches establish new rules for scope of practice or referrals and 

involve nontraditional providers in the care of patients with specific diseases. The 

nontraditional providers are paid a special fee contingent on improving health outcomes or 

lowering costs; 

4. Centers of excellence focus on particular disease episodes for high-cost, high-volume 

diseases and select a network of hospitals, physicians, and other providers who are already 

organized to receive a prospective, bundled payment per episode of care.”48

The January 1, 2006 implementation of Medicare Part D prescription drug benefit has 

resulted in some new concerns for the coordination of pharmaceutical coverage for some 
23 

Medicare and Medicaid recipients. Under the new Part D program, beneficiaries dually eligible 

for both programs will no longer be able to secure their prescription drug coverage through 

Medicaid and will be expected to enroll in a Medicare prescription drug plan, although there is 

uncertainty about whether they will receive equivalent coverage. A large proportion of 

chronically ill Medicaid patients are dually eligible, and state Medicaid officials are concerned 

that current disease management strategies may not be sufficient in the face of these changes.49

We have provided a brief description of several Medicaid care coordination projects in Table 

2 and direct interested readers to their website36 for case studies of ongoing disease management 

efforts among states. 

Table 2. Medicaid research projects with elements of care coordination 

Report/Program Description Results/Status 

Medicaid Disease 

Management: 

Issues and 

Promises, 200447

This report examines disease management programs 

in 9 states (CO, FL, IN, MD, MO, NY, NC, OR, WA) 

that target chronically ill beneficiaries in capitated 

managed care plans. 

-Cost savings and quality results were promising, 

but not conclusive 

-Difficulties with enrollee retention and low 

payment rates hindered the success of the disease 

management programs 

-Programs that focused on patient self-care, rather 

than making more comprehensive reform health 

system reforms through disease management were 

potentially missing the opportunity to address 

underlying problems of “poor coordination and 

communication, lack of quality improvement 

infrastructure, and the lack of attention to helping 

people avoid, rather than treat, chronic disease” 

Care 

Coordination and 

Medicaid 

Managed Care: 

Emerging Issues 

for States and 

Managed Care 

Organizations, 

200050

This report examines 5 state care coordination 

programs in managed care (CO, DE, NM,OR, WA) 

aimed at people with special health care needs. The 

report discusses the structure of care coordination 

requirements, implementation efforts, best practices in 

coordinated care, and lessons learned. 

-“Some states ... have led the way in mandating 

that Managed Care Organizations develop care 

coordination services to ensure that medical and 

social needs are identified and met” 

-“Care coordination programs take time to develop, 

but can be put in place even after a state has 

implemented Medicaid managed care” 

-“For the Medicaid managed care population, care 

coordination programs must be broader than simply 

expanding case management to include referrals for 

social service” 

-Creative problem-solving, through advocacy is 

emerging as an important new role for care 

coordinators” 

Washington State 

Medicaid 

Integration 

Partnership, 

started in 200551

This program targets elderly and disabled Medicaid 

beneficiaries in Snohomish county. Benefits include 

medical care, substance abuse treatment, and mental 

health treatment, with long term care to begin in 2006. 

The program involves care coordinators working with 

patients to identify health issues early, coordinate 

services, and help patients follow through with 

treatment. 

The first year impact report is scheduled to be 

released February, 2007 

For more information, go to: 

http://fortress.wa.gov/dshs/maa/mip/ 

Florida: A 

Healthy State 

Initiative52

 

Launched in 2001, Florida identified Medicaid 

beneficiaries with at least asthma, diabetes, congestive 

heart failure and/or hypertension who were high 

utilizers of specific medical services. These patients 

received an intensive care management program 

administered by an outside vendor. 

Evaluations report favorable financial, clinical and 

participant (patient, physician, case manager) 

results. Specifics are available at: 

http://www.floridahealthy.org/resources/programevaluation/ 
24 

Although we have highlighted several Medicaid programs and studies, publicly available 

research is somewhat limited on the effectiveness of disease management in Medicaid 

populations. While several modes of delivering care coordination exist, it is difficult to state 

with certainty whether these programs are effective. Research in this sector appears promising, 

but there is a need for more in-depth evaluations of state Medicaid disease management 

programs. 

Department of Veterans Affairs 

In 2003, the Department of Veterans Affairs (VA) established the Office of Care 

Coordination to support the implementation of a nationwide care coordination program. This 

effort is in addition to ongoing coordination activities (geriatrics evaluation and management 

units, coordinated spinal cord injury centers, aging interventions, integrated HIV care, etc), 

which are not covered further in this section. The VA’s care coordination efforts (through the 

centralized office) focus on the use of appropriate information technologies to connect patients to 

healthcare services within the VA. Telehealth technologies, supported by the VA’s existing 

computerized medical record system, are being used to help ensure that patients receive “the 

right care at the right time.”53 Specifically, telehealth is expected to reduce clinic visits, improve 

access to care, help avoid the cost and hassle of travel to distant VA facilities, enhance patient 

satisfaction, and be more cost efficient compared to usual care.53 

At present, the VA has initiated three telehealth care coordination systems. First, the Home 

Telehealth system allows patients to connect with providers from their homes. This program is 

targeted at patients with conditions that can impair their ability to make frequent office visits, 

such as diabetes, chronic heart failure, chronic obstructive pulmonary disease, post traumatic 

stress disorder, depression, and spinal cord injury. All patients involved with the VA’s Care 

Coordination/Home Telehealth (CCHT) programs are supported by a care coordinator, who can 

be a physician, but is usually a registered nurse, a nurse practitioner, or a social worker.54 Care 

coordinators manage between 90 and 150 patients, depending on the complexity of the patient 

population.54 As of September 2005, almost 9,000 patients were enrolled in CCHT care, with 

21,000 to 25,000 expected to be enrolled in September of 2006.54

Second, the General Telehealth system allows patients to connect with remote specialists via 

telehealth technologies within a VA clinic. The principal areas of interest for this program are 

telemental health, telerehabilitation, teleendocrinology, and telesurgery. Third, the Store-andForward approach to digital imagery enables digital images to be obtained and reviewed by a 

specialist remotely. This approach is common in the fields of radiology, dermatology, and 

retinal imaging—especially for patients with diabetes.53

According to the May 18, 2005 congressional testimony of Patricia S. Ryan, the Director of 

the Community Care Coordination Service in Veterans Integrated Service Network 8, patient 

satisfaction with the care coordination process as well as ease in use of the telehealth technology 

was above 95% for the past several years.55 A non-randomized study of a CCHT program for 

diabetes showed a reduction in hospitalizations, emergency room use, and the average number of 

bed days of care, and improvements with respect to health-related quality of life.56 Other recent 

studies of the VA’s telehealth care coordination efforts, including those with more rigorous 

designs, report favorable results in terms of patient and provider satisfaction,57, 58 utilization 

(including reductions in primary care visits initiated by a care coordinator,59 bed days, and urgent 

visits),60 clinical outcomes,61 and cost.60 
25 

Other Federal Programs 

The U.S. Congress passed the Patient Navigator Outreach and Chronic Disease Prevention 

Act of 2005, and the President signed the bill on June 29, 2005, to authorize the Secretary of the 

Department of Health and Human Services—through the Administrator of the Health Resources 

and Services Administration, and with participation of the Indian Health Service, the National 

Cancer Institute, the Office of Rural Health Policy—to make grants for the development and 

operation of demonstration programs to provide patient navigator services to improve health care 

outcomes.62 Two of the roles stated for a patient navigator by the legislation explicitly involve 

coordination: 1) assisting in the coordination of health care services and provider referrals, for 

individuals who are seeking detection services or follow-up for cancer or other chronic disease; 

and 2) coordinating with the health insurance ombudsman programs to address coverage needs. 

The legislation authorized appropriations of $25 million over five years starting in fiscal year 

2006. 

Another recent national effort to enable care coordination (among other improvements to the 

health care delivery system) took the form of an executive order: “Incentives for the Use of 

Health Information Technology and Establishing the Position of the National Health Information 

Technology Coordinator.”63 To provide leadership for the development and nationwide 

implementation of an interoperable health information technology infrastructure that does not 

rely on federal funding, but rather develops through collaboration between public and private 

interests, the President ordered a new position within Health and Human Services, “The National 

Health Information Technology Coordinator (National Coordinator).” The policy directive to the 

Coordinator specifies development of “an effective infrastructure for the secure and authorized 

exchange of health care information” that “improves the coordination of care and information 

among hospitals, laboratories, physician offices, and other ambulatory care providers.” 

Private Sector Developers and Purchasers 

In 2002, a survey found that nearly 90% of healthcare systems and managed care 

organizations reported they had or were developing disease management programs.64 Health 

insurers and integrated systems are among the biggest customers of care coordination and 

disease management vendor services. Expanded coverage of drugs by Medicare has led 

pharmacy benefits management firms to work with disease management vendors in product 

offerings to the private sector.65 These same organizations sometimes develop their own diseasefocused coordination programs. Recently, reports about obesity management have indicated that 

health insurers are certifying centers of excellence for bariatric surgery, and playing a patient 

channeling and coordinating role themselves.66 Some integrated health systems, such as Kaiser, 

have in-house care management programs67 that they have developed. Other groups have 

developed their own programs for the Medicare Coordinated Care Demonstration, including one 

integrated delivery system (Carle Foundation), four hospitals or academic medical centers, one 

hospital consortium, a retirement community, a long-term care provider and a hospice. The 

other six organizations in this demonstration are working with care coordination providers 

(outsourcing services).42
26 

2C. Professional Specialty Associations 

Specialty associations, representing the diverse views of physicians, nurses, pharmacists, 

patients, and care management advocates have increasingly developed policy statements 

regarding key aspects of the care coordination debate. Physician groups, such as the American 

Academy of Pediatrics,68 the American Academy of Family Physicians (AAFP),69 the American 

College of Physicians (ACP),70 the Society of General Internal Medicine (SGIM),71 the Society 

for Primary Care,33 and the American Geriatric Society (AGS)8

 generally support care 

coordination efforts and have even advocated financial incentive programs for physicians 

performing coordination tasks. In his 2004 testimony, before the Practicing Physicians Advisory 

Council, Thomas J. Weida of the AAFP called for a care management reimbursement fee for 

patients with chronic conditions stating that, “Effective chronic care management involves 

developing a partnership with each patient, developing a care plan, ongoing communication and 

coordination of disparate systems to integrate their care, patient education resources and delivery 

systems, and more. This consumes additional physician time and resources and requires 

different models of delivering care.”72 Similarly, Robert Berenson of the Urban Institute, in his 

2004 congressional testimony, advocated physician reimbursement for chronic disease care 

management and criticized Medicare’s current approach as a “corporate one, focused on 

providing contracts to third-party vendors, rather than directly enabling professionals to better 

serve their patients.”73 Recently, the ACP published a policy monograph on “The Advanced 

Medical Home: A Patient-Centered, Physician-Guided Model of Health Care” that calls upon 

fundamental changes to the health care system, where “physicians are once again partners in 

coordinating and facilitating care to help patients navigate the complex and often confusing 

health care system by providing guidance, insight and advice in language that is informative and 

specific to patient needs.”74

Other specialty groups, such as the American Psychological Association and the American 

Academy of Pediatrics Council on Children with Disabilities, have highlighted the unique care 

coordination needs of children and adolescents with mental health issues and other special needs. 

A 2005 Society of Primary Care policy paper entitled, “Healthy, Wealthy and Wise: Expanding 

the Medical Home,” proposed the development of centers that would coordinate and integrate a 

host of medical and social programs, such as disease management, case management, home 

visits, financial and debt management, exercise programs, and life skills training to vulnerable 

populations.75 

Groups like the Disease Management Association of America (DMAA) and Case 

Management Society of America (CMSA) are also working to bring attention to their causes. 

The DMAA is undertaking research efforts involving the standardization of disease management 

definitions, the standardization of outcomes evaluation metrics, and the development of a disease 

management patient and provider satisfaction measurement tools, among other activities. They 

have also recently published a dictionary of disease management terminology and a guide to 

disease management program evaluation, both of which are tools to help examine disease 

management program performance.76 Likewise, the CMSA also works to shed light on the 

importance of case management by educating healthcare consumers, providers, payers, and 

regulators.77 
27 

2D. Patient and Family Associations 

Patient advocacy groups have also taken a keen interest in care coordination activities. The 

Palliative Care Policy Center’s Care Coordination Coalition put forth recommendations at the 

2005 White House Council on Aging, which included paying for physician’s care coordination 

services and ensuring continuity of patient records across settings and time.78 At a 2002 

conference supported by the Commonwealth Fund, the Center for Medicare Advocacy also 

developed a set of recommendations for a Medicare coordinated care benefit, which called for 

improved care but not reduced costs to be the primary goal of services to patients and advocated 

the use of a care coordinator to oversee the health and social services for patients.79 

Caregiver alliances, such as the National Family Caregivers Association and the National 

Alliance for Caregiving, also highlight the role of caregivers as care coordinators, and even 

provide information about services offered by independent caregivers.80

2E. Conferences 

There has been a proliferation of conferences providing an opportunities to discuss 

contemporary issues in care coordination.81-84 For example, the 2002 Aspen Transitional Care 

Conference sought to explore reasons for failures to appropriately provide transitions in care 

between settings, to define the responsibility for care transitions for health professionals, and to 

develop a research agenda for interventions designed to evaluate and improve transitional care.82 

The seventh annual conference of The Disease Management Association (DMAA) discussed the 

standardization of disease management measures and processes to evaluate both clinical 

effectiveness and return on investment.85 Other organizations across the public and private 

sectors held care coordination conferences or workshops in 2006 (Table 3). 

Table 3. Example conferences in 2006 with care coordination themes 

Organization/Conference Title/Date Conference Highlights 

Managed Healthcare Executive, 3rd

Annual Optimizing the Implementation of 

Predictive Modeling, March 200686

Sessions include: 

-“Leveraging predictive modeling to improve outcomes in population care 

management”; 

 - “Moving from traditional medical management to care coordination and 

health promotion” 

Department of Health Policy Jefferson 

Medical College, The Disease 

Management Colloquium, May 200687

Sessions include: 

-“Achieving and measuring return on investment (ROI) from disease 

management initiatives; 

-Case studies in the Medicare and Medicaid initiatives in chronic care; 

-The role of disease management in consumer driven health plans; 

-The role of financial incentives, including pay for performance, in 

implementing disease management programs; 

-The role of health information technology in implementing disease 

management programs” 

Case Management Association of 

America, One Purpose, Many Paths, June 

200683 

Keynote talk on “Integrated Care Management: Moving from Vision to 

Reality” to address the issue that “patients want to have a seamless, 

personal and holistic experience.” 

Disease Management Association of 

America, 

Disease Management Leadership Forum, 

December 2006.88

Focus on personalized health care, information technology and 

association’s roll-outs of participant satisfaction survey tool, consensus 

guidelines on measuring outcomes, and care management predictive 

modeling. 
28 

The themes of these conferences suggest a growing interest in the many dimensions of care 

coordination programs, as health care decisionmakers strive to gain a better understanding of 

conceptualizing, implementing, measuring, and evaluating coordination processes. 

2F. Other Activities Described by Care 

Coordination Professionals 

 Through a series of Internet and literature searches using care coordination terminology, we 

identified and spoke with professionals actively involved in care coordination efforts to learn 

more about the key issues facing the field. Our professional contacts ranged from people 

involved with federal efforts to implement care coordination programs to private sector disease 

management companies, policy institutes that work with State Medicaid directors, health 

provider organizations, health plans, academic researchers, foundations, specialty advocacy 

group representatives, and clinical professional organizations. Through our conversations with 

care coordination professionals, we aimed to identify critical areas of controversy and common 

interest in the field, and the key gaps in the care coordination evidence base. 

Questions of Interest to Care Coordination Decisionmakers 

Defining and Conceptualizing Care Coordination. 

• How should care coordination be defined? 

• How can care coordination be conceptualized for purposes of implementation and 

evaluation? 

• How do various professions (e.g., nurses, physicians, hospice and social workers) understand 

care coordination? What are the similarities and differences in their points of view? 

Structuring Care Coordination Programs. 

• What would the optimal care coordination program look like? 

• How to coordinate care for multiple chronic conditions? 

• What existing systems do you need in place for care coordination to be most effective? 

• How to increase access to care coordination schemes? 

• How to apply a care coordination model to every day people, not just those with high risk, 

chronic conditions? 

• How do you best train people to do care coordination? What is the ideal training/skill 

set/caseload? 

• What is the role of information technology in care coordination? 

• Who should pay for care coordination? What financial incentives are needed? 

Coordination Settings.

• Where in the care continuum is coordination most likely to break down? 

• How to coordinate care across settings? 
29 

• How to coordinate care that falls outside of traditional healthcare setting, such as consumer 

directed healthcare purchases, and work and school based management programs? 

• What care coordination program will work best in my setting (or across settings that my 

organization might influence)? 

Patient Groups To Target. 

• Which patient groups would benefit most from care coordination? 

• Which patient groups are most likely to have poor coordination experiences? 

• How does care coordination vary by disease, race, and/or age of the population? 

Provider and Patient Roles. 

• What should be the patient’s role in a given care coordination scheme? 

• How does care coordination differ according to the health care provider’s role? Is what a 

physician does to promote care coordination different from what a nurse does? 

• Who is responsible for coordinating care of a complex patient who is managed in multiple 

settings by multiple providers? 

• What’s the best provider skill mix to make care coordination happen? What methods work to 

obtain buy-in for coordinating care from usual care physician? 

• How do recent efforts in pay for performance and consumer driven health care influence 

respectively provider and patient coordination responsibilities? 

Assessing Care Coordination. 

• How should care coordination be measured? 

• How much do care coordination programs cost? Are they cost effective? 

• What outcomes should be measured to ascertain if care coordination is making a difference? 

Over what period of time? 

• Does care coordination lead to decreased hospitalization and repeat testing? 

• Will care coordination demonstrate a return on investment? What methods are appropriate to 

measure return on investment? 

• Will people be less sick if care coordination is implemented? 

• Is coordinating care better than doing nothing? 

• Are patients more satisfied with care when it is coordinated better? 

• Is care coordination more apt to increase the timeliness of care? 

• What is the impact of care coordination on caregivers? Are caregivers satisfied and does it 

help? 

• What is the relationship between the way care coordination is structured and its 

effectiveness? 

• Does the degree of a health plan’s integration affect how well care coordination works? 
30 

Key Gaps in the Care Coordination Evidence Base 

Measures. 

• Care coordination metrics to measure if coordination is occurring and how it is working. 

• Metrics for calculating costs and savings associated with care coordination. 

Evidence. 

• Evidence on the efficacy of care coordination. 

• Identification of best practices for care coordination. 

• Guidelines for coordination of care of patients with multiple chronic conditions. 

• Research on care coordination as it pertains to patients with chronic conditions. 

• Relative effectiveness of integrated, practice-centered approaches versus “carve out” 

approaches (e.g., vendor supplied disease management or external case management). 

Conceptual Frameworks. 

• A consensus definition of care coordination. 

• Common terminology/vocabulary for describing and evaluating care coordination. 

• A model for implementing and evaluating care coordination. 

• Framework for describing and relating the elements of care coordination. 

• Different considerations and needs depending upon perspective (e.g., broad systems level 

perspective with responsibility for longitudinal, population-based care versus health care 

delivery perspective concerned with managing handoffs between care providers). 

• Research models on how best to coordinate care for specific healthcare settings and patient 

populations. 

• A model of communication that will allow diverse provider groups to better interact. 

Other. 

• Effects of widespread use of electronic medical record to help facilitate coordination. 

• Caregivers role in care coordination schemes. 

• Effects of reimbursement for performing care coordination tasks. 

• Effects of improved integration across specialties. 

2G. Summary Answers to Key Questions 

Research Question 1: What Aspects of Care Coordination Are 

of Greatest Interest to Healthcare Decisionmakers? 

Among health professionals, the lack of a care coordination definition and conceptual model 

were key areas of concern. These deficiencies were considered barriers to effectively evaluating 

and assessing care coordination processes. Additional evidence regarding the influence of care 
31 

coordination programs on health, cost, and satisfaction outcomes was also frequently noted. 

Many decisionmakers wanted to know if care coordination actually worked, and, if so, how it 

affects costs. Furthermore, those with responsibility for managing health care sought answers 

for what approaches to care coordination were likely to work, under which circumstances (e.g., 

by disease, setting, geographical region, payor), and for which patient populations. Finally, of 

interest to all decisionmakers, was the development of measures and approaches to examine the 

effectiveness and quality of care coordination interventions. 

Research Question 2: What Are the Key Gaps in the Care 

Coordination Evidence Base? 

The care coordination field would benefit from consensus definitions, conceptual models, 

and measures of care coordination processes. However, the dearth of evidence surrounding the 

efficacy and cost-effectiveness of various care coordination programs are also pressing issues 

facing decisionmakers. They want practical answers about what to implement to improve care 

coordination, and yet the field is only just emerging as an area of concerted study from a 

conceptual as well as a pragmatic perspective. Additionally, the private sector is playing a major 

role in providing care coordination services, yet specific details about the extent and the 

effectiveness of their programs is not generally available to the public. 

33 

Chapter 3. Definitions of Care Coordination and 

Related Terms 

3A. Background and Objectives 

Confusion about the definition of care coordination makes studying this topic particularly 

challenging. Throughout the project, experts have underscored the critical need for a consensus 

definition. Without a common definition, it was not feasible to determine what should be 

included as a care coordination intervention in our review of systematic reviews. As a result, we 

aimed in this chapter to develop a list of available definitions, discuss their common elements, 

and ultimately present a working definition to guide our review of systematic reviews. Although 

a more involved consensus process is advisable for developing a universally accepted definition, 

we expect that the development of our working definition will be a helpful initial step for others 

attempting standardization in this area. 

3B. Methodological Approach 

We adopted an iterative literature search approach to identify definitions of care 

coordination, from which we developed a preliminary working definition of care coordination. 

Table 4 presents examples of targeted literature search strategies of the PubMed®, CINAHL®, 

and Health and Psychological Instruments (HaPI) databases. Articles from these searches fell 

broadly into three categories: 1) presentations of explicit definitions or conceptual frameworks 

related to care coordination, 2) empirical studies that directly evaluated coordination processes, 

and 3) studies describing the development of measures of coordination processes. Given the 

breadth of coordination-related research identified in our preliminary searches, and because the 

purpose of this report was to provide a cross-cutting overview of the state of the science of care 

coordination research, searches were not used to perform a systematic review of primary studies 

of care coordination interventions. We instead retrieved selected articles from these searches for 

this chapter and Chapter 5 (conceptual frameworks), and did not attempt to be exhaustive. 

Table 4. Initial search strategies used to identify definitions of care coordination 

Database Search criteria 

PubMed “Coordination” and ((provider*) or (physician*)) and (“care” or (practice*) or (service*) or 

(task*)) and (“communication” or (organization*) or “programming” or “feedback”) 

 Coordinat* and “care” and ((theor*) or “model” or “framework” or (concept*) or (defin*)) 

 Coordinat* and “care” and measure* and (“testing” or “validation”) 

CINAHL ((Coordinat$ and care.mp and (instrument.mp or exp Instrument Validation/) 

HaPI Coordinat$ and care.mp 

* and $ are truncation symbols so that all terms starting with the letters before the truncation symbol are searched. For example, 

searching with the term theor* would include terms such as theory and theoretical. 

3C. Key Elements in Care Coordination Definitions 

Our searches found more than 40 distinct definitions of care coordination that were 

extremely heterogeneous (Table 5). 
34 

Table 5. Definitions for care coordination and related concepts 

Citation Definition 

AAP 199913

AAP 200568

"Care coordination is a process that links children with special health care needs 

and their families to services and resources in a coordinated effort to maximize 

the potential of the children and provide them with optimal care." (1999) 

"Care coordination is a process that facilitates the linkage of children and their 

families with appropriate services and resources in a coordinated effort to achieve 

good health." (2005) 

Allred 199589 "Coordination is the ability to achieve the requisite unity of effort or teamwork 

across individuals, departments, and organizations so that the activities necessary 

for the organization's success do not go unperformed. Coordination implies 

collaboration or an integration of efforts, of which communication among 

individuals and groups is the basis."; "Coordination is the technique used to 

satisfy the information needs of the numerous and diverse providers 

(differentiation) that are required to contend with patient care problems that arise 

in a complex, rapidly changing, unpredictable, and uncertain practice 

environment." (citing Charns 1976) 

Allred 199590 "Coordination refers to the regulation of activity between the nurse and the case 

manager so that necessary patient activities do not go unperformed" (citing 

Charns 1976) 

Bickell 200191 "We developed a conceptual framework that posited 6 dimensions of 

coordination for early-stage breast cancer: standardization of work, feedback 

mechanisms, patient support, monitoring the quality of care, information systems, 

and location of care sites." 

Bodenheimer 199992 "The PCP [primary care practitioner] as coordinator assists patients in receiving 

the full range of medical services from the multitalented team of specialists and 

other caregivers" 

Bolland 199493 - "Coordination is a term that is often used without any exact referent, and in 

some cases, researchers report lack of coordination without either (a) indicating 

an empirical basis for their conclusions, or (b) indicating what empirical findings 

they would accept as evidence of coordination"; 

- "Integrative coordination": "when the interorganizational system is structurally 

fragmented, coordination is low; when it is structurally integrated, coordination is 

high" 

Brown 200442 "The term 'care coordination' has no well-established definition. Rather, it is 

generally understood to mean a process of improving communication among the 

various medical professionals with whom patients come in contact and between 

these professionals and the patients themselves (and their families)." 

Cassady 200094 "Coordination addressed only the actual integration of services between a 

primary care provider and specialty care, because consumers might not know the 

characteristics of the practice (structure) that facilitate coordination of care” 

Chen 200032 - "There does not seem to be a clear, universally accepted definition of 

coordinated care for chronic illness.” 

- “Coordinated care programs, by our definition, are those that target chronically 

ill persons 'at risk' for adverse outcomes and expensive care and that meet their 

needs by filling the gaps in current health care. They remedy the shortcomings in 

health care for chronically ill people by (1) identifying the full range of medical, 

functional, social, and emotional problems that increase patients' risk of adverse 

health events; (2) addressing those needs through education in self-care, 

optimization of medical treatment, and integration of care fragmented by setting 

or provider; and (3) monitoring patients for progress and early signs of problems. 

Such programs hold the promise of raising the quality of health care, improving 

health outcomes, and reducing the need for costly hospitalizations and medical 

care." 
35 

Table 5. Definitions for care coordination and related concepts (continued) 

Citation Definition 

Cooley 200395 Coordination themes: role definition, family involvement, child and family 

education, assessment of needs/plans of care, resource information and referrals, 

advocacy 

Fletcher 198496 - Coordinated care components: "written evidence that the other physician was 

aware of the primary physician's involvement, and that 1) the primary physician 

arranged visit to the other physician or knew about it beforehand; or 2) the 

primary physician was aware of the patient's visit to the other physician after the 

visit" 

- Fletcher et al. “did not consider these components acts of coordination in 

themselves, but rather conservative markers of the coordinating process." 

Flocke 199897 "Coordination of care refers to the incorporation of information from referrals to 

specialists and previous health care visits into the current and future medical care 

of the patient." 

Flocke 199798 "Coordination of care is defined as the patients' perception of their physician's 

knowledge of other visits and visits to specialists, as well as the follow-up of 

problems through subsequent visits or phone calls." 

Forrest 200099 "Optimal coordination involves the documentation of patient care activities, 

interprovider communication, and the integration of service delivery into a single 

medical home" (citing Institute of Medicine 1996100 and Starfield 1998101) 

Gilbert 1995102 "Coordinated care is a multi-disciplinary approach that focuses on achieving 

patient outcomes within effective time frames which have been established by all 

members of the health care team involved in the treatment of specific patient 

populations. The key to this model is the development of critical paths which 

serve as a guideline for interventions to be accomplished to achieve the desired 

outcome. Deviations from the critical path are documented and analyzed to 

determine system issues. An assigned coordinator is responsible for initiating the 

critical paths and monitoring patient progress." 

Gittell 2000103 "Relational co-ordination: co-ordination carried out by front-line workers with an 

awareness of their relationship to the overall work process and to other 

participants in that process. Relational co-ordination is characterized by frequent, 

timely problem solving communication and by helping, shared goals, shared 

knowledge, and mutual respect among workers. It is essentially a network of 

communication and relationship ties among workers, and can be thought of as a 

form of organizational social capital likely to enhance organizational 

performance." 

Gittell 2002104 "Coordination may be facilitated by certain design elements but it is more 

fundamentally a process of interaction among participants...Relational 

coordination reflects the role that frequent, timely, accurate, problem-solving 

communication plays in the process of coordination, but it also captures the oftoverlooked role played by relationships...specifically, coordination is carried out 

through relationships of shared goals, shared knowledge, and mutual respect." 

Gittell 2004105 Coordination is an "activity that is fundamentally about connections among 

interdependent actors who must transfer information and other resources to 

achieve outcomes" 

Glasgow 2005106 Follow-up/Coordination: "Arranging care that extends and reinforces officebased treatment, and making proactive contact with patients to assess progress 

and coordinate care" 

Guastello 2005107 "Coordination occurs when two or more people do the same or complementary 

tasks simultaneously." 

Healey 2004108 "Coordination refers to a team's performance enhancement of function through 

managing and timing activities and tasks." 

 
36 

Table 5. Definitions for care coordination and related concepts (continued) 

Citation Definition 

Hoenig 2001109 "Coordination of care was measured according to (a) number of different staff 

meetings, b) how often the therapists at team meetings (rounding therapists) were 

the same therapists treating the patient (treating therapists) versus someone 

providing a report from the treating therapist, and (c) use of paid escorts to 

transport patients to therapy." 

IOM 1996100 "Coordination ensures the provision of a combination of health services and 

information that meets a patient's needs and specifically means the connections 

within and across those services and settings - putting them in the right order and 

appropriately using resources of the community. The goal is to focus on 

interactions with patient and family and their health concerns, clarify clinical care 

decisions, advise hospitalized patients and their families, and help patients and 

their families cope with the social and emotional implications of disease or 

illness." 

IOM 2004110 "To establish and support a continuous healing relationship, enabled by an 

integrated clinical environment and characterized by the proactive delivery of 

evidence-based care and follow-up. Clinical integration is further defined as the 

extent to which patient care services are coordinated across people, functions, 

activities and sites overtime so as to maximize the value of services delivered to 

patients. Coordination encompasses a set of practitioner behaviors and 

information systems intended to bring together health services, patient needs, and 

streams of information to facilitate the delivery of care in accordance with the six 

aims set forth in the Quality Chasm report. Such coordination can be facilitated 

by procedures for engaging community resources, including social and public 

health services." (synthesized from several sources2, 6, 111) 

Kibbe 2001112 "Care coordination is a term that encompasses a variety of care management 

methods - from case to disease management - that aim to improve the quality of 

care provided to patients with chronic illness while decreasing avoidable costs 

associated with their delivery...care coordination is viewed by its practitioners 

(mostly specially trained nurse case managers) as a method for decreasing the 

fragmentation of health delivery sites and, through better planning and 

monitoring of patient care plans, ending the confusion and uncertainty that often 

attend care for patients with complicated illnesses or multiple medical problems. 

Care coordination also is a means to increase the likelihood that patients with 

chronic illness will achieve recommended care and adhere to best practices for 

specific illnesses and conditions. Finally, care coordination is a collaborative and 

team approach that recognizes the importance of keeping the attending physicians 

informed while enhancing information sharing and communication among 

providers so as to maintain a fabric of continuity." 

Kinsman 2000113 - "[Coordination] pertains to the systems aspect of the service delivery system.” 

- “[Coordination requires models of team functioning. The complexity of spina 

bifida...requires the perspectives, knowledge bases and skills of a wide variety of 

professionals. How these different groups work together and integrate is what 

comprises [coordination]." 

Kodner 2002114 "Coordination, the middle ground in integrated care, entails the development of 

formal structures and mechanisms to bridge the gap between providers and 

institutions, as well as work around system weaknesses and barriers, without 

fundamentally changing these systems per se. A variety of techniques are 

employed, including uniform assessment procedures, care management, joint care 

planning, team care, standardized guidelines and protocols, and common clinical 

and service records." 

 
37 

Table 5. Definitions for care coordination and related concepts (continued) 

Citation Definition 

Lima & Brooks 1985115 Assessment of coordination between medical and community mental health 

center: "Coordination of care with the [community mental health center] was 

noted as present if a telephone call, or letter, or a review of the psychiatric chart 

had taken place...coordination with the medical clinic could have taken place 

through a telephone call, a letter, or a review of the medical chart." 

Longest & Klingensmith 

1994116

- "Conceptually and historically, coordination has been defined as the conscious 

activity of assembling and synchronizing differentiated work efforts so that they 

function harmoniously in attainment of organization objectives." 

- Extending the definition to encompass both inter- and intraorganizational 

situations: "coordination is conscious activity aimed at achieving unity and 

harmony of effort in pursuit of shared objectives within an organization or among 

a set of organizations participating in a multiorganizational arrangement of some 

kind." 

Malone & Crowston 1994117 "Coordination is managing dependencies between activities." 

Massachusetts Consortium for 

Children with Special Health 

Care Needs Care Coordination 

Work Group 2006118

"Care coordination is a central component of an effective system of care for 

children and youth with special health care needs and their families. Care 

coordination is an ongoing process which engages families in development of a 

care plan and links them to health and other services that address the full range of 

their needs and concerns. Principles of care coordination reflect the central role of 

families and the prioritization of child and family concerns, strengths and needs 

in effective care of children with special health care needs. Activities of care 

coordination may vary from family to family, but start with identification of 

individual child and family needs, strengths and concerns, and aim 

simultaneously at meeting family needs, building family capacity and improving 

systems of care." 

McGuiness & Sibthorpe 

2003119

"We conceived of coordination as a complex construct, incorporating both 

overall impacts of care as well as discrete key processes. Questionnaire items 

were designed to capture aspects of coordination that were grouped into six 

domains: identification of need, access to care (drugs, tests or imaging, and 

services); patient participation, including empowerment; patient-provider 

communication; inter-provider communication; and global assessment of care." 

National Quality Forum 2006120 "Care coordination is a function that helps ensure that the patient’s needs and 

preferences for health services and information sharing across people, functions, 

and sites are met over time. Coordination maximizes the value of services 

delivered to patients by facilitating beneficial, efficient, safe, and high-quality 

patient experiences and improved healthcare outcomes." 

Ohlinger 2003121 Coordination components: communication, multidisciplinary input, consistency 

in practice 

Parchman 2005122 "Coordination of care refers to the degree to which information from various 

sources is incorporated by the physician into the care the patient receives." 

Parkerton 2004123 “Practice Coordination” is referred to as “system continuity” 

Pollack 2003124 Coordination construct: "Degree to which relationships with other units in the 

hospital facilitate ICU performance" 

 
38 

Table 5. Definitions for care coordination and related concepts (continued)

Citation Definition 

Reid 2002125 - “The core element of the interaction between an individual and health care 

providers helps distinguish continuity from other concepts that are often used 

synonymously. For instance, if the focus is on the interaction among providers, 

then the concept reflects co-ordination and integration not continuity. As [the] 

Director of Research at the Alberta Mental Health Board ... said, ‘Continuity is 

how patients experience co-ordination between providers.’” 

- Management continuity refers to “the provision of separate types of healthcare 

over time in ways that complement each other so required services are not 

missed, duplicated or poorly timed.” 

- “Although co-ordination refers specifically to the interaction between providers 

– and thus is not strictly continuity – it should result in the patient sensing 

‘management continuity’, which means the care received from different providers 

is connected in a coherent way.” 

- Management "continuity is measured by the extent to which care is given in the 

correct sequence, at the proper time and in the clinically appropriate manner." 

Rosenbach & Young 200050 - "There is no standard definition of care coordination.” 

- “Care coordination programs tend to use a broader social service model that 

considers a patient's psychosocial context (such as housing needs, income, and 

social supports...may coordinate a full range of medical and social support 

services offered within and outside the managed care plan...typically arrange 

covered and non-covered services for patients." 

Shortell 1994126 “Coordination refers to the extent to which functions and activities both within 

the unit and between units are brought together in a way that promotes costeffective continuous care." (citing Longest & Klingensmith 1994116) 

Sprague 2003127 “All of these concepts [disease management, case management, care 

coordination, care management] have in common the principle of getting a 

person clinically appropriate care in a timely manner without wasting resources. 

Care coordination seeks primarily to help a patient navigate the system, working 

across care settings and providers and frequently accessing other services, such as 

personal care or community programs, as well." 

Starfield 1979128 "Coordination of care was defined as the recognition of information (problems, 

therapies, intervening visits and tests) about patients from one visit to a follow-up 

visit." 

Temkin-Greener 2004129 "The degree to which: work activities within a team are coordinated through 

formal plans, protocol, schedules; and face to face interactions are perceived as 

effective." 

U.S. Department of Veterans 

Affairs Office of Care 

Coordination 84 (Accessed 

August 29,2005) 

"Care coordination in VHA is the wider application of care and case management 

principles to the delivery of health care services using health informatics, disease 

management, and telehealth technologies to facilitate access to care and improve 

the health of designated individuals and populations with the intent of providing 

the right care in the right place at the right time" 

Van de Ven 1976130 "Coordination means integrating or linking together different parts of an 

organization to accomplish a collective set of tasks." 

 
39 

Table 5. Definitions for care coordination and related concepts (continued)

Citation Definition 

Wehr 2000131 - "No validated measure of the quality of care coordination exists. Indeed, there 

is no single, generally accepted definition of 'care coordination'.” 

- “Care coordination was 'opening doors' to needed services for Medicaid 

enrollees and helping them with non-medical problems that could compromise 

their health." 

- "The purpose of care coordination is to assist persons with special health care 

needs and their families gain access to services covered under their Medicaid 

managed care plan and to other services available in their communities." 

- "Care coordination is support by an information system dedicated to care 

coordination and linked to other MCO information systems...requires a written 

plan of care based on a comprehensive assessment of the goals, capacities, and 

medical condition of the consumer and the needs and goals of family 

caretakers...includes monitoring to assure that services are received, to identify 

problems in the quality of care, to reassess and revise care plans, and to advocate 

on behalf of enrollees and family caretakers." 

Wenger 2004132 Coordination is a "'process by which the elements and relationships of medical 

care during any one sequence of care are fitted together in an overall 

design....coordination involves the sharing of information about past findings, 

evaluation, and decisions, and the use of these in current management, among a 

number of providers to achieve a coherent scheme of management"(citing 

Donabedian 1980133); "matching the patient's needs with the appropriate level and 

type of medical, health, and social services" (citing JCAHO134) 

Young 1998135 "Coordination has been defined as the conscious activity of assembling and 

synchronizing differentiated work efforts so that they function harmoniously in 

attainment of organizational objectives." (citing Haimann & Scott 1990) 

From a review of these definitions and related studies, we identified five key elements 

comprising care coordination: 

1. Numerous participants are typically involved in care coordination; 

2. Coordination is necessary when participants are dependent upon each other to carry out 

disparate activities in a patient’s care; 

3. In order to carry out these activities in a coordinated way, each participant needs adequate 

knowledge about their own and others’ roles, and available resources; 

4. In order to manage all required patient care activities, participants rely on exchange of 

information; and 

5. Integration of care activities has the goal of facilitating appropriate delivery of health care 

services. 

The subsequent sections provide more detail about each of these five themes and how they 

relate to the health care setting. 

Participants Involved in a Patient’s Care 

Patients, family caregivers, physicians, nurses, pharmacists, social workers, other 

professionals, and support staff are often involved in delivery of health care services. As care 

needs become more complex, the number of potential participants and relationships among 
40 

participants tends to increase. For example, care of an otherwise healthy patient with 

uncomplicated hypertension may be effectively managed by a single primary care physician. In 

contrast, care for seriously mentally ill patients could typically include physicians, nurses, social 

workers, psychologists, and pharmacists as core team members, but might also involve 

occupational or recreational therapists, dietitians, and chaplains depending on the specific 

patient’s unique needs.136 Similarly, management of care for frail community-dwelling elderly 

people optimally involves primary care physicians, nurse practitioners, clinic and home health 

nurses, social workers, occupational and physical therapists, dietitians, healthcare workers or 

aides, recreation therapists, and transportation workers, as evidenced by the Program of AllInclusive Care for the Elderly (PACE).129 Regardless of the number of participants, the patient 

and his or her needs are highlighted in care coordination definitions from several prominent 

organizations (e.g., AAP, IOM, NQF). 

Interdependence of Participants 

Coordination for patients with complex health care needs often involves multiple participants 

who individually provide specialized knowledge, skills, and services*, and who together 

potentially provide a comprehensive, coherent, and continuous response to a patient’s unique 

care needs.** Three vignettes in a recent policy monograph by the American College of 

Physicians provide concrete examples highlighting the need for highly coordinated delivery of 

care when multiple participants depend on each other to provide appropriate care.†

Adequate Knowledge About Available Resources 

and Participants’ Roles 

In order to make appropriate and timely medical decisions, participants in patient care 

activities require information about available resources (e.g., information systems, urgent care 

facility availability at a particular hour, standardized protocols). They also need adequate 

information about the experience, skills, plans, relationships, and preferences of all participants 

in order to determine a plan of care.13, 95, 103, 104, 113, 116, 137-139 Clinicians involved in a patient’s 

care may also have differing opinions about the roles they and others should assume in a 

patient’s care.140 Such discrepancies in perceptions about roles may lead to ineffective 

navigation back and forth across boundaries related to professions, geography, information 

systems, and organizations.8, 9, 12, 141 Effective coordination depends on adequate knowledge 

 

*

 Organizational theory refers to this concept as “differentiation,” while health care often uses the term 

specialization. 

** Similarly, organizational theory calls this concept “complementarity,” while the health care field would simply 

refer to this situation as providing patient care. 

†

 In one of the cases, an internist asked a home healthcare nurse to assess an 85-year old woman with congestive 

heart failure, atrial fibrillation, type 2 diabetes mellitus, and possible dementia who had been deteriorating at home. 

After evaluating the patient, the nurse provided a video link to the patient’s home and discussed the patient’s 

situation with the internist who recommended that paramedics be called. While the paramedics prepared to transfer 

the patient to the hospital, the nurse notified the granddaughter. The patient was stabilized in the hospital, received a 

cardiology consultation, and was finally discharged home with ongoing monitoring supported by the home 

healthcare nurse, granddaughter, and internist. 
41 

about roles and interdependencies among participants,117 and ways to reduce system weaknesses 

and barriers through “bridging gaps” in information flow.142 

Information Exchange Among Participants 

Many of the definitions in Table 5 and studies of coordination interventions describe the pivotal 

role of exchange of critical patient-related information to facilitate effective coordination and 

medical decisionmaking.90, 96, 98, 99, 102, 115, 122, 143, 144 Several studies have found that referring 

clinicians and specialists exchange information infrequently99, 145, 146 and in non-standardized 

ways that may have adverse consequences for patient care.91 

The Aims of Care Coordination 

Most definitions of care coordination state a purpose for coordination. While approaches to 

coordinating care may vary greatly, the general intent of these strategies is to facilitate delivery 

of the right health care services in the right order, at the right time, and in the right setting.100, 127, 

147 Thus, care coordination occurs with the deliberate purpose of achieving a goal, such as the 

appropriate delivery of health care. Such delivery is particularly challenging wherever care must 

span role, physical, or time boundaries (e.g., the primary care/specialty care interface; the health 

care/community interface; continuity of services among various care sites such as inpatient, 

outpatient, and nursing home for the elderly; and transitions over time in cases such as 

adolescents moving into adult services). 

3D. Proposed Working Definition of Care Coordination 

We brought together the key elements found in the published definitions of care coordination 

and developed a definition that addresses these elements in a single brief statement. We also 

recognized that we would need to apply the proposed working definition to our literature review, 

and therefore attempted to keep it as simple and inclusive as possible. We purposefully chose to 

be broad and inclusive because we did not want to miss systematic reviews that might be 

relevant to any reasonable concept of care coordination. Narrower definitions may be useful for 

other purposes. In Section 3F, we introduce a components list to guide analysis of care 

coordination interventions. 

We define care coordination as 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 marshalling 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.

3E. Terminology Closely Related to Care Coordination 

Several terms have often been used synonymously or in conjunction with care coordination: 

collaboration, teamwork, continuity of care, disease management, case management, care 
42 

management, Chronic Care Model, and care or patient navigator. As is the case with care 

coordination, some of these terms lack a consensus regarding their definition and use in actual 

practice,64, 125, 148-150 making it difficult to interpret how these concepts relate to each other and to 

care coordination. However, each of these models seeks to reduce fragmentation and improve 

health care delivery through better coordination.32, 42, 151, 152 

Since the boundaries between these terms is blurry and each of the models they represent 

have substantial overlap with care coordination (as described in our working definition), we 

retained these additional terms in our searches to identify articles possibly relevant to care 

coordination. 

Collaboration 

Numerous investigators have defined inter-professional collaboration153-163 as interactions 

based on shared power and authority153 and mutual respect for the unique abilities of each 

participant.154 Ideal collaborative relationships among health professionals result in cooperative 

problem-solving and decisionmaking,155 where participants achieve better patient care by 

working together than would have been possible individually.156 While some classify 

coordination as a concept that is a subset of collaboration,163 others describe collaboration as one 

possible approach to coordinating care.117 Thus, there is agreement that the concepts of 

collaboration and coordination are related, even if there is ambiguity about how they overlap. 

Teamwork 

In health care, multidisciplinary teams commonly include “individuals from different 

disciplines who contribute specialized knowledge in nonhierarchical relationships and who act 

according to situational demands rather than traditional organizational roles.”136 Identifying 

determinants of successful teamwork in health care has generated much interest.164-168 For 

example, mutual adjustments among participants to coordinate care is logically necessary as the 

level of interdependence among the participant’s separate activities increases.130

 

Continuity of Care 

This concept is often mentioned in conjunction with care coordination or care transitions,96, 

132, 169 and also has multiple definitions.170-178 Described by some as the “existence of some 

thread, individual, practitioner, group, or medical record that binds together episodes of care,”96

continuity of care has also been defined as “effective information exchange, within satisfactory 

patient-clinician relationships”.179 While some investigators define coordination as one of 

several domains within continuity of care,180 others suggest that coordination results from 

continuity of care.125

The interested reader is referred to discussion papers125, 181, 182 and a recent review 

commissioned by several Canadian organizations183 for a synthesis of the conceptual work on 

continuity of care. In brief, their work organizes continuity of care into three dimensions: 

informational continuity, or the “use of information on past events and personal circumstances to 

make current care appropriate for each individual;” interpersonal continuity, defined as an 

“ongoing therapeutic relationship between a patient and one or more clinicians;” and 
43 

management continuity, defined as a “consistent and coherent approach to management of a 

health condition that is responsive to patient’s changing needs.” Continuity of care represents an 

individual patient’s experience of coordination over time with either a single clinician or with 

multiple clinicians (i.e., the extent to which the appropriate care is perceived to occur at the right 

time and in the right order).125, 181, 183

Disease Management 

The Disease Management Association of America defines this term as “a system of 

coordinated healthcare interventions and communications for populations with conditions in 

which patient self-care efforts are significant. Disease management supports the physician or 

practitioner/patient relationship and plan of care, emphasizes prevention of exacerbations and 

complications utilizing evidence-based practice guidelines and patient empowerment strategies, 

and evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of 

improving overall health.”184 Full-service disease management programs include the following 

six components: processes to identify specific population, evidence-based practice guidelines, 

practice models based on collaboration between physicians and other supporting service 

providers, self-management education for patients, measurement of process and outcomes, 

routine reporting to provide a feedback loop among participants.184 In addition, disease 

management and case management programs have been included together under the umbrella of 

“coordinated care models” in reports intended to guide the Medicare Coordinated Care 

Demonstration Projects.32, 42 

Case Management 

The Case Management Society of America defines case management as “a collaborative 

process of assessment, planning, facilitation and advocacy for options and services to meet an 

individual’s health needs through communication and available resources to promote quality 

cost-effective outcomes”.185 According to a Mathematica report that included case management 

in its definition of care coordination, “case management implicitly enhances care coordination 

through the designation of a case manager whose specific responsibility is to oversee and 

coordinate care delivery [targeted to] high-risk patients [with a] diverse combinations of health, 

functional, and social problems.”32

Care Management

This term is often used interchangeably with care coordination. In a background paper, 

Mechanic states “care management programs apply systems, science, incentives, and information 

to improve medical practice and help patients manage medical conditions more effectively. The 

goal of care management is to improve patient health status and reduce the need for expensive 

medical services. The principal challenge is finding effective ways to change physician and 

patient behavior.”67
44 

Chronic Care Model 

Initially named by Wagner and colleagues as a “Model for Effective Chronic Illness Care”, 

the basic premise of this model is that “effective chronic illness care requires an appropriately 

organized delivery system linked with complementary community resources available outside 

the organization” and is sustained by productive interactions between multidisciplinary primary 

care teams and “activated patients.”142, 149, 186-189 A multidisciplinary primary care practice team 

has responsibility for organizing and coordinating care through a number of activities: 

performing comprehensive patient assessments; helping patients set goals and solve problems for 

improved self-management; applying clinical and behavioral interventions that prevent 

complications and optimize disease control and patient well-being; and ensuring continuous 

follow-up. To achieve effective patient management, the Chronic Care Model promotes 

comprehensive system change encompassing six broad areas: health care organization, linkages 

to community resources, self-management support, delivery system redesign, decision support, 

and information systems. Further extensions (Barr et al’s Expanded Chronic Care Model190, 

WHO Model of Innovative Care),191 include components that provide more detail on community 

linkages, offer supplementary aims of population health through preventive services and health 

promotion, and add a policy environment level. 

Care Navigator or Patient Navigator 

These terms appear on web sites of health care organizations, particularly for cancer care, 

and in reports in the medical literature.192 Recent studies report patient navigator interventions in 

inner-city women with breast abnormalities,193 a university hospital head and neck cancer 

service,194 a community hospital using lay people as navigators for cancer patients,195 and as part 

of a collaborative community health initiative for uninsured patients.196 While there is no 

standard definition of a patient navigator, authors of a literature review recently recommend 

defining a navigator as “someone who helps assist patients overcome barriers to care,” instead of 

employing the other common service-based definition.192 Thus, patient navigation refers to the 

assistance offered to patients in “navigating” through the complex health-care system to 

overcome barriers in accessing quality care and treatment (e.g., arranging financial support, 

coordinating among providers and setting, arranging for translation services, etc). The National 

Cancer Institute also emphasizes a patient-centric model, noting that “a navigator is someone 

who understands the patient's fears and hopes, and who removes barriers to effective care by 

coordinating services, increasing a cancer patient's chances for survival and quality of life.”197

Although more commonly available for cancer patients, patient navigation is used for 

underserved patients with other chronic conditions. 

One other related area deserves special mention: telehealth and information systems. As 

noted in Chapter 2, the VA’s central care coordination program relies on the role of information 

technologies to connect patients to services. This approach is covered by two other AHRQ 

Evidence Reports, and is therefore not duplicated in our review. The RAND EPC produced both 

a searchable tool198 and a review of the evidence from existing published articles regarding the 

costs, benefits, and barriers to implementing health information technologies.199 The Oregon 

Health Sciences EPC recently updated an evidence report on telemedicine for the Medicare 

population that focused on health outcomes and access to care for store-and-forward, home-
45 

based and office/hospital-based services.200 While neither of these reports directly addressed the 

role of information systems to improve care coordination, they both offer some relevant findings. 

The Oregon report identified several studies showing benefits of home-based telemedicine 

interventions in chronic diseases, apparently resulting partially from enhanced communication 

with health care providers and dependent to some degree upon changes in staffing as well as the 

technology enhancements. The RAND report concluded that the evaluative evidence base for 

effects of information technologies on patient-centeredness is sparse, and described only one 

study that commented on enhanced coordination. A recent overview noted that the emerging 

telehealth environment poses a critical need to clarify roles and assess skills for effective 

interaction between patients and clinicians.201

3F. Components of Care Coordination 

Peer reviewers of a draft of this report suggested that care coordination be broken into 

component parts for the purpose of analysis of care coordination interventions. Since there is no 

standard set of components of care coordination, we developed our own list of components that 

make up various care coordination interventions. We assembled this list from multiple sources, 

including the ongoing demonstration projects noted in Chapter 2, elements of our working 

definition and related terms discussed earlier in Chapter 3, ideas from the concepts present in 

frameworks described in Chapter 5, and recent work by the National Quality Forum (NQF)120

and Mathematica under contract to CMS.202 We then grouped related ideas and developed a 

more parsimonious list of tasks related to care coordination and features to support the tasks. 

The essential tasks are focused on the clinician-patient interaction (e.g., assess the patient), and 

the associated coordination activities (e.g., identify need for coordination), while the common 

features typically involve systems, resources or even policy changes to enable these tasks (e.g., 

personal health record to supply necessary information to multiple providers). Table 6 

summarizes our component list and the correspondence of each component to the domains (and 

principles) from two other systems (NQF, Mathematica). The NQF system aimed to provide a 

framework for development of measures of care coordination, and drew from medical home 

concepts articulated by AAP, AAFP and ACP as well as other input from multiple sources. 

Mathematica has been evaluating best practices in care coordination to guide CMS 

demonstration projects, and continues to evolve a classification framework with readily observed 

program features, in order to relate domains of care coordination to program impacts. 

The goal of our list of components of care coordination is to help answer the question: what 

intervention components are required for each permutation of specific circumstances that 

complicate the delivery of coordinated care? We could hypothesize that patients who have 

mental illnesses see multiple caregivers, and therefore interventions with components that 

emphasize communication among caregivers might be particularly important to successful 

coordination. In other words, an intervention without this active ingredient—an effective 

communication strategy, perhaps depending on a feature such as the proposed Continuity of Care 

Record203, 204—would not improve coordination among mentally ill patients. Likewise, we might 

hypothesize that medication reconciliation is vital for frail elderly patients transitioning between 

settings, and that interventions with systems that support this activity (e.g., a standard procedure 

to review medications with a patient or family member prior to prescribing) would work better 

than those without such a component. As various interventions are developed, the common 
46 

features list could be expanded–with new categories and more examples. In addition, the task 

categories may be more or less than needed. 

We developed this list as a tool to characterize the presence and absence of intervention 

components in recent systematic reviews. We demonstrate the approach here with a recent 

article of an ongoing study, “Geriatric Resources for Assessment and Care of Elders (GRACE) 

model”, that was devoted entirely to a comprehensive description of an intervention to improve 

coordination and delivery of high quality care to low-income seniors, a group particularly 

vulnerable to system disconnects.205 Table 7 shows our decomposition of this intervention into 

coordination-related components from our list. 
Table 6. Components of care coordination 

Component NQF Domains and Principles MatESSENTIAL CARE TASKS and Associated Coordination Activity ASSESS PATIENT Determine Likely Coordination Challenges 

Highlights specific populations more vulnerable to disconnected care [Principle] 

Initi

DEVELOP CARE PLANPlan for Coordination Challenges and Organize Separate Care Plans

“Proactive Plan of Care and Follow-upestablished and current care plan”[Domain] Prob

Care 

IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES Specify Who Is Primarily Responsible For Coordination 

“Healthcare ‘home’ – source of usual care selected by patient” [Domain] 

ProgProv

COMMUNICATE TO PATIENTS AND ALL OTHER PARTICIPANTS Ensure Information Exchange Across Care Interfaces 

“Communication-available to all team members, including patients and family” [Domain] 

Com

EXECUTE CARE PLAN Implement Coordination Interventions 

 Serv

MONITOR AND ADJUST CARE Monitor For And Address Coordination Failures 

 Ong

EVALUATE HEALTH OUTCOMES Identify Coordination Problems That Impact Outcomes 

As appropriate, measurement targeted all participants [Principle] 

QuaOutc

COMMON FEATURES OF INTERVENTIONS TO SUPPORT COORDINATION ACTIVITIES and ExamplesINFORMATION SYSTEMSElectronic medical record; Personal health record; Continuity of care record, Decision support ; Used for population identification for intervention

“Information systems - the use of standardized, integrated electronic information” [Domain] 

InfoElec

TOOLS Standard protocols, Evidence-based guidelines, Self-management program, Clinician education on coordination skills, Routine reporting/feedback 

 Pati

TECHNIQUES TO MITIGATE INTERFACE ISSUES Multidisciplinary teams for specialty and primary care interface; Case manager or patient navigators to network and connect between medical and social services; Collaborative practice model to connect different setting or levels of care; Medical home model to support information exchange at interfaces 

“Transitions/Handoffs - transitions between settings of care are a special case because currently they are fraught with numerous mishaps” [Domain] 

SYSTEM RE-DESIGNPaying clinicians for time spent coordinating care; Changes that reduce access barriers including system fragmentation, patient financial barriers - lack of insurance, underinsurance, physical barriers - distance from treatment facilities

47
Table 7. Application of component list to well-described primary study 

Intervention Description Component Categorization 

GRACE support team acts as catalyst, provides care management, and consists of a nurse practitioner and a social worker 

Care Task: Identify Participants/ Specify Roles Associated Coordination Activity: Specify Who is Responsible for Coordination 

Support team given role of 

Upon enrollment, the GRACE support team meets with the patient in the home to conduct an initial comprehensive geriatric assessment 

Care Task: Assess Patient Associated Coordination Activity: Determine Coordination Challenges 

Comprehensanticipates sneeds for co

The support team meets with GRACE interdisciplinary team (including a geriatrician, pharmacist, physical therapist, mental health social worker, and community-based services liaison) to develop an individualized care plan including activation of GRACE care protocols for common geriatric conditions 

Care Task: Identify Participants Care Task: Develop Care Plan Feature to Support Coordination Activities: Tools 

Interdiscipliidentified expStandard prosupport coorcare physicia

The GRACE support team meets with the patient’s primary care physician (PCP) to discuss and modify the plan 

Care Task/Coordination Activity: Communicate/ Ensure Information Exchange Across Care Interfaces Feature to Support Coordination Activity: Technique to 

Mitigate Interface Issues 

Primary careaddressed wimeeting 

Collaborating with the PCP, the support team implements the plan 

Care Task: Execute Care Plan 

With support of electronic medical record and longitudinal Web-based care management tracking system, the GRACE support team provides ongoing care management and coordination of care across geriatric syndromes, providers, and care sites 

Care Task/Coordination Activity: Monitor and Adjust Care/ Monitor and Address Coordination Failures Features to Support Coordination Activity: Information Systems, Tool, Technique to Mitigate Interface Issues 

Electronic msystem), a trasupport team monitor coorand settings 

The goal of the GRACE model is to optimize health and functional status, decrease excess healthcare use, and prevent long-term nursing home placement 

Care Task: Evaluate Health Outcomes Coordination Activity: Identify Coordination Problems 

that Impact Outcomes 

Evaluation bmeasures to 

48
49 

3G. Summary Answers to Key Questions 

Research Question 3: What Definitions Exist for Care Coordination? 

The term, “care coordination,” is referred to often in the health services literature, but is less 

frequently explicitly defined. The more than 40 definitions of coordination identified in our 

search pertain to a diverse set of patient populations, healthcare scenarios, and organizational 

situations. While definitions vary depending on their purpose and audience, they share common 

elements. We combined these elements into a working definition for application to our 

systematic review, and potential use by others. Table 8 shows how these common elements are 

specified in our working definition. 

Table 8. Elements common to care coordination definitions, and linkage to our working definition 

Common element Phrase from our working definition 

Coordination has a purpose or 

goal 

“the deliberate organization...to facilitate the appropriate delivery of health 

care services” 

Numerous participants involved in 

a patient’s care 

“organization of patient care activities between two or more participants 

involved in a patient’s care” 

Adequate knowledge about 

available resources and 

participants’ roles 

“organizing care involves the marshalling of personnel and other resources 

needed to carry out all required patient care activities” 

Information exchange among 

participants 

“managed by the exchange of information among participants” 

Coordination is necessary when 

participants are interdependent 

“participants responsible for different aspects of care” 

 

Research Question 4: What Definition Could be Formulated To Apply 

to Systematic Reviews? 

Systematic reviews require clear definitions to determine reliably which articles are within 

the scope of a review. We chose to define care coordination to meet two objectives: 1) to 

incorporate the main elements of other definitions, and 2) to simplify decisions about whether an 

article is pertinent to the topic of care coordination or not. Our working definition of care 

coordination presented in this chapter is purposely broad enough to include interventions that are 

sometimes defined by their own related terminology (e.g., disease management, case 

management, teamwork, collaboration, Chronic Care Model). It is also applicable to programs, 

such as the Medicare demonstration projects to improve care for those with chronic illness. The 

objective of these interventions and programs is to improve quality of care, in part or in total by 

enhancing coordination between participants for the benefit of the patient (improved outcomes) 

and the system (reduced costs). 

We also developed a list of components of care coordination to support a more granular 

analysis of interventions. The components are separated into essential care tasks (e.g., identify 

participants and their roles), their associated coordination activities (e.g., coordinate among care 

plans), and common features of interventions to support coordination activities (e.g., 

standardized protocol, multidisciplinary team). The list draws extensively from components 

described by clinical professional organizations, recent consensus development efforts by the 

National Quality Forum, and intervention evaluators.

51 

Chapter 4. Review of Systematic Reviews of Care 

Coordination Interventions 

4A. Background 

Increasingly, aspects of care coordination are being evaluated. In this chapter we provide a 

summary of this evidence by synthesizing systematic reviews of care coordination interventions 

intended to improve the quality of care of outpatients. Our intent was to describe the broad 

extent of the care coordination literature regarding outpatient care coordination programs. We 

did not limit our review to a specific clinical area or patient population. 

4B. Methodological Approach 

We sought articles reporting systematic reviews of care coordination interventions to 

improve quality of care provided to patients. We used our working definition of care 

coordination presented in the previous chapter to inform our inclusion and exclusion criteria. 

Inclusion and Exclusion Criteria 

We searched for English language systematic reviews of care coordination interventions, 

irrespective of clinical condition, patient population, or specific outcomes. We considered an 

article to be a systematic review, if, at a minimum, the authors described conducting a systematic 

review, and performed a defined literature search. 

We included reviews in which interventions were conducted either exclusively in an 

outpatient setting or were conducted across settings and included the outpatient setting (i.e., were 

started in an in-patient setting but continued in the outpatient setting). We also included 

systematic reviews where only a part of the review evaluated a care coordination intervention 

(typically, these were articles in which the reviews had a broader focus than care coordination 

but where some of the included articles met our definition of care coordination). 

We excluded reviews where the only two participants were a clinician and the patient 

because these situations presumably have lower demands for coordination activities. We also 

excluded reviews that did not report evaluations of care coordination interventions and those 

reviews that were conducted solely in an inpatient setting. 

 

Search Strategy 

We initially searched the following databases with the help of a research librarian: 

MEDLINE® (through April 7, 2005), CINAHL® (through May 17, 2005), Cochrane database of 

systematic reviews (through June 2, 2005), American College of Physicians Journal Club 

(through June 2, 2005), Database of Abstracts of Reviews of Effects (through June 2, 2005), 

PsychInfo (through June 2, 2005), Sociological Abstracts (through June 3, 2005), and Social 

Services Abstracts (through June 3, 2005). We searched with terms that were either synonymous 

with the term “coordination” or terms which have been used in the literature to suggest care 
52 

coordination, as indicated by our work on definitions of care coordination (Chapter 3) and 

discussions with experts and librarians, including: “disease management,” “case management,” 

and “patient care planning.” We restricted our search to systematic reviews using the search 

strategy developed by Shojania et al.206 

In response to comments received by our peer reviewers, we updated our search through to 

September 30, 2006 for MEDLINE® and to November 15, 2006 for the remaining databases. 

Complete search strategies for each database are presented in Appendix A*

. We performed 

additional data abstraction (described below) on these additional reviews, referred to as “the 

most recent reviews.” 

Data Abstraction and Evaluation 

A single investigator reviewed titles and abstracts of each article identified in our search to 

determine whether the article met inclusion criteria. Investigators identified those articles about 

which they were unsure. These articles were then reviewed and discussed by the full research 

team and agreement on inclusion or exclusion for full text review was reached by group 

consensus. Two independent investigators reviewed and abstracted all articles requiring full text 

review. Disagreements on extracted data were discussed and resolved by the research team by 

reviewing the article. Additionally, the investigators met regularly and engaged in an active 

dialogue about specific articles. 

From each of the included reviews, we abstracted data about whether the entire focus of the 

review or only a partial focus was on care coordination. For those reviews where the entire focus 

was on care coordination, we abstracted data on the research methodology used, setting of the 

care coordination intervention, terms and definitions used to describe the care coordination 

intervention, and the reported outcomes. For those reviews that only partially focused on care 

coordination, we limited our data abstraction to the purpose of the review, the care coordination 

strategies included, and outcomes. The complete full-text abstraction form is provided in 

Appendix B*

. 

In response to comments received from our peer reviewers, we also abstracted information, 

from the most recent reviews, on specific components of the care coordination intervention 

(Chapter 3, Table 6). We sought information on components of the specific care coordination 

intervention (e.g., case management, disease management) as well as whether details about the 

care coordination components were provided by the review. 

Quality Assessment of Reviews 

We assessed the quality of the systematic reviews by abstracting information about specific 

systematic review research methodology criteria (Appendix B). These criteria have been used 

previously by the drug effectiveness review project of the Oregon Evidence-based Practice.207

Statistical Analysis 

Given the heterogeneity of the included articles, we were limited in our ability to conduct 

quantitative analyses of the data. We report the results of our review as a narrative synthesis. 

 

*

 Appendixes cited in this report are provided electronically at http://www.ahrq.gov/clinic/tp/caregaptp.htm 
53 

4C. Results 

Results of Literature Search and Article Review Process 

The results of our search strategy and article review process are presented in Figure 1. Our 

searches yielded 4,730 potentially relevant articles of which 429 articles merited full-text review. 

Of these, 75 systematic reviews met our eligibility criteria for data abstraction. Appendix C*

provides the citations of articles excluded after the full text review, along with the reason for 

exclusion. 

Figure 1. Search results 

 

*

 Appendixes cited in this report are provided electronically at http://www.ahrq.gov/clinic/tp/caregaptp.htm 

Cochrane 

18 citations 

CINAHL® 

1945 citations

Social Abstracts 

37 citations 

Total number of potentially 

relevant articles 

4730

MEDLINE®

2717 citations 

PsychInfo 

13 citations 

4301 exclusions 

Not a systematic review: 2270 

Not care coordination: 1988 

In-patient setting only: 43 

Stage 1: Article title and 

abstract review 

Total number of articles 

requiring full text review 

429

354 exclusions 

Not a systematic review: 168 

Not care coordination: 157 

In-patient setting only: 7 

No intervention evaluated: 8 

Other reason: 14 

Articles meeting criteria for 

data abstraction 

75

Stage 2: Article full text review 

Articles with entire focus on 

care coordination 

43

Articles with partial focus on 

care coordination 

32
54 

In the sections that follow, we present 1) the results of the 43 reviews for which care 

coordination was the sole focus of the systematic review, 2) narrative syntheses of systematic 

reviews by common care coordination strategies and common patient populations, followed by 

the results of the 32 systematic reviews for which care coordination was only a partial focus and, 

3) components of the interventions described in the most recent systematic reviews. 

Summary of Reviews With Entire Focus on Care Coordination 

We identified 43 reviews that focused entirely on one or more care coordination strategy. 

These reviews were highly heterogeneous with respect to the care coordination interventions 

evaluated, their definitions, and the clinical topics evaluated (Tables 16a-k). 

Quality Assessment of Reviews 

Table 9 presents the results of our quality assessment of the included reviews. Overall, most 

of the reviews were rigorously conducted. All of them reported a research question. All but 

three of the reviews reported the specific search terms used and time frame covered by the 

search; five reviews did not provide specific inclusion/exclusion criteria. The quality of the 

reviews regarding the data abstraction process was mixed: 18 of the 43 reviews reported 

title/abstract review by at least two reviewers; 23 reported data abstraction by at least two 

reviewers and explained how disagreements between reviewers were resolved. About threequarters of the included reviews provided some assessment of the validity of the articles they 

included in their analysis, almost all provided sufficient details on each individual article, and all 

provided an appropriate synthesis (either narrative, quantitative or both) of their results. Seven 

reviews reported using a research librarian to help with their search and 19 reviews included a 

topic or methods expert as part of their team (Figure 2). 

Figure 2. Quality assessment of reviews 

-60% -40% -20% 0% 20% 40% 60% 80% 100%

Appropriate synthesis

Details presented

Validity assessment

Article retrieval effort made

Time frame reported

Search strategy reported

Research team

Disagreement resolution

Dual data abstraction

Dual abstract review

Selection criteria stated

Purpose stated

Met criterion Criterion not met Not stated
Table 9. Quality assessment of reviews with entire focus on care coordination 

Reference Purpose 

stated 

Inclusion/ 

exclusion 

criteria 

stated 

Dual title/

abstract 

review 

Dual data 

abstraction

How 

disagreements 

resolved 

Research 

team 

Search 

terms 

reported 

Time 

frame 

covered

Effort 

made to 

find all 

articles

Validi

assessm

of inclu

article

Multidisciplinary teams 

 Mental health Bower 2000208

●

●

○

●

● Not stated

●

●

●

●

Craven 2006209

●

● Not stated

●

●

■, ▲

●

●

●

●

Gunn 2006210

●

●

○

○

●

■, ▲

●

●

●

○

Latimer 1999211

●

○

○

○

○ Not stated

○

○

●

●

Marshall 2000212

●

●

●

●

○ Not stated

●

●

●

●

Simmonds 2001213

●

●

●

●

● Not stated

●

●

●

●

Wadhwa 1999

g214

●

● Not stated

●

● Not stated

●

●

●

●

Ziguras 2000

g215

●

● Not stated Not stated

○

▲

●

●

●

●

 Heart failure Holland 2005216

●

●

●

●

●

■

●

●

●

●

McAlister 2004217

●

●

●

●

●

▲

●

●

●

●

McAlister 2001*218

●

●

●

●

●

▲

●

●

●

●

 Stroke Langhorne 2005219

●

●

●

●

●

■, ▲

●

●

●

●

55
 Table 9. Quality assessment of reviews with entire focus on care coordination (continued) 

Reference Purpose 

stated 

Inclusion/ 

exclusion 

criteria 

stated 

Dual title/

abstract 

review 

Dual data 

abstraction

How 

disagreements 

resolved 

Research 

team 

Search 

terms 

reported 

Time 

frame 

covered

Effort 

made to 

find all 

articles

Validi

assessm

of inclu

article

 Palliative care Higginson 2003220

● ● ● ● ○ ▲ ● ● ● ● 

 No specific clinical focus LemieuxCharles 2006221 ● ● Not stated Not stated Not stated Not stated ● ● ● ○ Richards 2003g222

● ● Not stated ● ○ ▲ ● ● ● ● 

Disease management

 Mental health NeumeyerGromen 2004223 ● ● Not stated Not stated ○ Not stated ● ● ● ●  Heart failure Göhler 2006224 ● ○ Not stated ● ● ▲ ● ● ● ○ Roccoforte 2005225

● ● ● ○ ● ▲ ● ● ● ○ 

Whellan 2005226

● ○ Not stated Not stated Not stated Not stated ● ● ● ○ 

Yu 2006227 ● ● Not stated Not stated Not stated Not stated ● ● ● ○  Diabetes Knight 2005228 ● ● ● Not stated ● ▲ ● ● ● ● Norris 2002g152 ● ● Not stated Not stated ○ ▲ ● ● ● ●  Multiple clinical focus Krause 2005229 ● ● ○ ○ ○ Not stated ● ● ● ○ 

56
 Table 9. Quality assessment of reviews with entire focus on care coordination (continued)

Reference Purpose 

stated 

Inclusion/ 

exclusion 

criteria 

stated 

Dual title/

abstract 

review 

Dual data 

abstraction

How 

disagreements 

resolved 

Research 

team 

Search 

terms 

reported 

Time 

frame 

covered

Effort 

made to 

find all 

articles

Validi

assessm

of includ

article

 Rheumatoid arthritis Badamgarav 2003230

● ● ● ● ● Not stated ● ● ● ● 

Case management 

 Mental health Gorey 1998231 ● ○ Not stated Not stated ○ Not stated ● ● ● ○ Marshall 1998232

● ● ● ● ● Not stated ● ● ● ● 

Heart failure 

Windham 2003233

● ● Not stated Not stated ○ ▲ ● ● ● ● 

 No specific clinical focus Payne 2002234 ● ● ● ● ● ■, ▲ ○ ● ● ● 

Integrated care 

 Mental health Jeffery 2000g235

● ● ● ● ● ▲ ● ● ● ● 

 No specific clinical focus Briggs 2006236 ● ● ○ ● ● ▲ ● ● ● ● Johri 2003237 ● ● Not stated Not stated Not stated Not stated ● ● ● ● 

Interprofessional education 

 Mental health Reeves 2001238 ● ● ○ ● ● Not stated ● ● ● ●  Pain management Irajpour 2006239 ● ● Not stated Not stated Not stated Not stated ● ● ● ● 

57
 Table 9. Quality assessment of reviews with entire focus on care coordination (continued)

Reference Purpose 

stated 

Inclusion/ 

exclusion 

criteria 

stated 

Dual title/

abstract 

review 

Dual data 

abstraction

How 

disagreements 

resolved 

Research 

team 

Search 

terms 

reported 

Time 

frame 

covered

Effort 

made to 

find all 

articles

Validi

assessm

of includ

article

 No specific clinical focus Zwarenstein 2001240

● ● ● ● ● Not stated ● ● ● NA 

Other care coordination interventions 

 Heart failure Philbin 1999241 ● ● Not stated Not stated ○ ▲ ● ● ● ○  Diabetes Greenhalgh 1994242

● ○ Not stated Not stated ○ ■, ▲ ○ ○ ● ○ 

 Asthma Ram 2005243 ● ● ● ● ● ■ ● ○ ● ●  Cancer Dohan 2005192 ● ● Not stated Not stated Not stated Not stated ● ● ● ○  No specific clinical focus Grimshaw 2006244

● ● ● ● ● ▲ ● ● ● ○ 

Gruen 2003245 ● ● ● ● ● Not stated ● ● ● ● McCusker 2006246

● ● ○ ● ● Not stated ● ● ● ○ 

Mitchell 2002247

● ● ● Not stated ○ Not stated ● ● ● ● 

Zwarenstein 2000248

● ● ○ ○ ○ Not stated ● ● ● ● 

● Yes ○: No ■: Research librarian assistance ▲: Topic or methods expert NA: not applicable (no include

* disease management programs; gcase management

58
59 

Systematic Review Characteristics 

The characteristics of each systematic review are presented in Table 10. Most of the 

included reviews restricted their included articles to either randomized controlled trials (RCT), or 

other controlled trials. Nine reviews did not restrict their inclusion criteria by study design. 

The clinical topics that the included reviews addressed were varied. Care coordination 

interventions for improving care to patients with mental health problems (13 reviews) was the 

most common topic studied followed by heart failure (9 reviews) and diabetes (3 reviews). 

Eleven reviews did not have a specific clinical area of focus but instead studied interventions that 

crossed diseases, such as discharge planning or interprofessional education (i.e., training 

individuals from different professions interactively). 

Eight of the reviews focused on elderly populations while most of the remaining reviews 

focused on adults in the general population for the specific disease of interest. Surprisingly, 

given the interest in care coordination for special need children, we did not find any reviews 

pertinent to this topic. 

Interventions in about half the reviews were conducted across multiple settings, for example, 

from hospital to home or community, in outpatient clinics and at home or in outpatient and 

specialist clinics. Five of the reviews did not provide information on the specific settings of the 

interventions. Few studies provided detail on other setting-related factors (e.g., public versus 

private, HMO versus not, etc.). 

Table 10. Selected characteristics of reviews with entire focus on care coordination 

Reference Study designs 

included 

Clinical focus Population 

studied 

Intervention setting 

Multidisciplinary teams 

Bower 2000208 RCT, CBA, ITS Mental health General population Outpatient 

Craven 2006209 All study designs Mental health General population Community, 

outpatient clinic, 

specialist facility 

Gunn 2006210 RCT Depression Adult general 

population 

Outpatient clinic 

Latimer 1999211 All study designs Severe mental illness General population Outpatient clinic, 

home 

Marshall 2000212 RCT Severe mental illness General population Community 

Simmonds 2001213 RCT, quasi-RCT Severe mental illness General population Community, home 

Wadhwa 1999g214 RCT, quasi-RCT Mental illness; 

terminal illness 

General population Home, community, 

hospice 

Ziguras 2000g215 Controlled studies Severe mental illness General population Community 

Holland 2005216 RCT Heart failure General population Home, hospital, 

outpatient clinic 

McAlister 2004217 RCT Heart failure Not stated Home, specialist 

facility 

McAlister 2001*218 RCT, quasi-RCT IHD General population Not stated 

Langhorne 2005219 RCT Stroke Elderly Community, hospital 
60 

Table 10. Selected characteristics of reviews with entire focus on care coordination (continued) 

Reference Study designs 

included 

Clinical focus Population 

studied 

Intervention 

setting 

Higginson 2003220 All study designs Palliative care General population Outpatient clinic, 

managed care, home, 

hospice 

Lemieux-Charles 

2006221

All study designs 

with a comparison 

group or analyzed 

across time 

No specific focus General population Outpatient clinic, 

home, Community, 

hospital 

Richards 2003g222 RCT No specific focus Elderly Outpatient clinic, 

hospital 

Disease management 

Neumeyer-Gromen 

2004223

RCT Major depression General population Managed care 

Göhler 2006224 RCT Heart failure General population Not stated 

Roccoforte 2005225 RCT Heart failure General population Outpatient clinic, 

hospital, home 

Whellan 2005226 RCT Heart failure General population Home, clinic 

Yu 2006227 RCT Heart failure Elderly Home, hospital, 

outpatient clinic 

Knight 2005228 RCT, CBA Diabetes Not stated Not stated 

Norris 2002g152 All comparative 

studies 

Diabetes General population Community, 

managed care 

Krause 2005229 Controlled studies; 

before-after studies 

Asthma, diabetes, 

heart failure 

General population Home, hospital, 

outpatient clinic 

Badamgarav 2003230 RCT, quasi-RCT, 

CBA, ITS 

Rheumatoid arthritis General population Outpatient clinic 

Case management 

Gorey 1998231 RCT, quasi-RCT, 

pre-experimental 

Severe mental illness General population Community 

Marshall 1998232 RCT Severe mental illness General population Community 

Windham 2003233 All study designs CHF Elderly Outpatient clinic, 

home, specialist 

facility 

Payne 2002234 All study designs No specific focus Elderly Community, hospital, 

home, nursing home 

Integrated care 

Jeffery 2000g235 RCT Severe mental illness; 

substance abuse 

General population Specialist facility 

Briggs 2006236 RCT, CBA, ITS No specific focus General population Outpatient clinic 

Johri 2003237 RCT, quasi-RCT No specific focus Elderly Community 

 
61 

Table 10. Selected characteristics of reviews with entire focus on care coordination (continued)

Reference Study designs 

included 

Clinical focus Population 

studied 

Intervention 

setting 

Interprofessional education 

Reeves 2001238 All study designs Mental health General population Not stated 

Irajpour 2006239 RCT, quasi-RCT Pain management General population Community, hospital 

Zwarenstein 2001240 RCT, CBA, ITS No specific focus Not applicable – no 

included articles 

Not applicable – no 

included articles 

Other care coordination interventions 

Philbin 1999241 RCT, quasi-RCT, 

CBA 

CHF Elderly Not stated 

Greenhalgh 1994242 All study designs Diabetes General population Outpatient clinic, 

specialist facility 

Ram 2005243 RCT Asthma General population Outpatient clinic 

Dohan 2005192 Not specified Cancer General population Community, clinic 

Grimshaw 2005244 RCT, CBA, ITS No specific focus General population Outpatient clinic 

Gruen 2003245 All study designs No specific focus General population Outpatient clinic, 

hospital 

McCusker 2006246 All study designs No specific focus Elderly Community, hospital, 

home, outpatient 

clinic 

Mitchell 2002247 RCT No specific focus General population Outpatient clinic, 

hospital, home 

Zwarenstein 2000248 RCT, quasi-RCT, 

CBA, ITS 

No specific focus General population Hospital 

RCT: randomized controlled trial; CBA: controlled before-after study; ITS: interrupted time-series design; * disease 

management programs; gcase management; CHF: congestive heart failure; HTN: hypertension; CAD: coronary artery disease; 

IHD: ischemic heart disease 

Care Coordination Strategies 

The terms used to define the care coordination strategies were highly heterogeneous; 43 

individual reviews reported 20 different care coordination interventions (Table 11). Most 

reviews reported on a single care coordination intervention, however, six reviews reported at 

least two types of interventions.152, 214, 217, 219, 222, 235 The most commonly used terms were 

multidisciplinary teams, case management, and disease management. Across reviews, there 

were varying definitions of the same care coordination term used (Tables 16a-k). For example, 

all ten reviews reporting on disease management152, 218, 223, 230 defined it differently (Tables 16ak). Nine reviews217, 224-226, 233, 235, 241, 244, 246 failed to provide a clear definition for the intervention 

under study; we included these reviews because the descriptions of the interventions of their 

included articles related to a care coordination strategy. 

Our review of the evidence, provided in the sections that follow, suggests that care 

coordination strategies may improve health outcomes. Given the heterogeneity of the different 

interventions studied, it is unclear whether one particular strategy is more likely to work than 
62 

others; however, interventions using multidisciplinary teams and disease management programs 

consistently reported improved outcomes. We provide further evidence to support this finding in 

our summary tables (Tables 16a-k) and in our narrative synthesis section below. 

Table 11. Distribution of reviews with entire focus on care coordination by care 

coordination intervention 

Care Coordination Intervention No. of Reviews 

Assertive community treatment 3211, 212, 215

Case management 8152, 214, 215, 222, 231-233, 235

Collaborative care 1209

Disease management 10 152, 218, 223-230

Geriatric assessment/evaluation and management 2222, 246

Integrated programs 3235-237

Interprofessional education 3 238-240

Key worker assigned coordination function 1234

Multidisciplinary clinic 1217

Multidisciplinary program (comprehensive) 1241

Multidisciplinary teams 10208, 210, 213, 214, 216-218, 220-222

Navigation program 1192

Nurse-doctor collaboration 1248

Organized specialty clinic 1243

Organized cooperation 1247

Shared care 1242

Specialist outreach clinic 1245

System level interventions 1210

Team coordination and delivery 1219

Team coordination 1219

Note: The intervention terms used in this table are the terms used by the systematic reviews; similar interventions 

may have slightly different terms. 

Outcomes Reported 

Due to the heterogeneity of clinical topics, settings, patient populations and interventions, the 

systematic reviews reported a broad range of endpoints. In many cases, there was not any 

quantitative summary across included studies. For the 16 systematic reviews with some patient 

or utilization outcome synthesized, Table 12 summarizes the specific endpoints reported 

quantitatively for five general categories: clinical outcomes, adherence outcomes, other patient 

experience outcomes, and utilization outcomes. Specific quantitative results are provided in the 

summary tables (Tables 16a-k).
Table 12. Quantitative outcomes reported by systematic reviews 

Reference Care coordination 

intervention 

Clinical Outcomes Adherence 

Outcomes 

Other Patient 

Experience 

Outcomes 

Gunn 2006210 System level interventions Recovery from depression

Marshall 2000212 Assertive community 

treatment (ACT) 

 Remain in contact 

with service 

Live independently; Become homeless; Unemployed 

Holland 2005216 Multidisciplinary 

interventions 

All-cause mortality 

McAlister 2004217 Multidisciplinary teams All-cause mortality 

Langhorne 2005219 Multidisciplinary teams Death or dependency 

Higginson 2003220 Palliative care teams Pain; other symptoms Satisfaction 

McAlister 2001218 Multidisciplinary disease 

management 

Recurrent myocardial 

infarction; all-cause 

mortality 

 Cardiovascular risk 

factors; quality of life 

Neumeyer-Gromen 2004223

Disease management programs 

Depression severity Treatment adherence Patient satisfaction 

Göhler 2006224 Disease management 

programs 

All-cause mortality 

Roccoforte 2005225 Comprehensive disease 

management program 

Mortality 

Yu 2006227 Disease management 

program 

Mortality Quality of life 

Knight 2005228 Disease management Glycated hemoglobin 

Norris 2002152 Disease management; case 

management 

Glycated hemoglobin 

Badamgarav 2003230 Disease management Functional status 

Irajpour 2006239 Interprofessional education Pain severity Documentation of 

pain history 

Philbin 1999241 Comprehensive, 

multidisciplinary program 

 Functional status; 

aerobic capacity; satisfaction 

63
64 

Costs 

Background. Given the costs associated with poorly coordinated care, even intensive care 

coordination interventions have the potential to be cost-saving. 

Results. 22 reviews reported some cost estimates or comparisons for the care coordination 

intervention under study (Table 13). The reported results were extremely heterogeneous. Only 

one review reported results from cost-effectiveness/cost-utility analysis223 that suggested disease 

management programs were cost-effective. Another review229 conducted a meta-analysis to 

evaluate the economic effectiveness of disease management programs. Krause229 reports 

economic effectiveness in terms of effect size which is a summary outcome measure created 

from the direct economic outcome measures (cost, hospitalizations, clinic visit, emergency 

department visit) reported in each individual study. The findings from this review suggest that 

disease management programs were economically effective. Nine reviews213, 215, 217-219, 222, 227, 231

reported lower costs for the care coordination intervention when compared to usual care; 

however, none of these reviews conducted any formal cost-effectiveness analysis. Seven 

reviews reported mixed cost results of the intervention208, 214, 220, 226, 233, 245, 247 and five reviews 

reported insufficient evidence to draw any definitive conclusions about the costs of 

interventions.211, 212, 232, 236, 241 (Table 13). 

Summary. We conclude that there is insufficient evidence from the included reviews to 

draw definitive conclusions about the costs associated with care coordination interventions.
Table 13. Reviews with entire focus on care coordination: cost results 

Reference Intervention No. of articles 

reporting cost 

data 

Results 

Bower 2000208 On-site mental health worker 3 Cost results were mixed; no formal cost-effectiv

increased costs for some patient groups and decr

Latimer 1999211 Assertive community treatment 

(ACT) 

34 ACT appears to have lower costs; however, redu

programs will be determined by the reduction in 

Marshall 2000212 Assertive community treatment 

(ACT) 

9 There was insufficient cost data reported in the a

between ACT and the control intervention. 

Simmonds 2001213 Community mental health team 

management 

5 Reported total cost of care; lower costs for comm

management compared to standard care (differen53%); data reported from articles was highly ske

Wadhwa 1999214 Multidisciplinary teams; case 

management 

10 Cost data provided in the 10 articles was insuffic

analysis. Half of the articles showed no differenintervention and control group. The other half shbetween the two groups with one article reportinintervention group. 

Ziguras 2000215 ACT; Case management 5 Case management was associated with lower tot

compared to usual treatment [Weighted mean r = 0.19), p=0.043]. 

McAlister 2004217 Multidisciplinary teams 18 No formal cost-effectiveness analysis conducted

interventions to be cost-saving; 3 reported interv

McAlister 2001218 Multidisciplinary disease 

management 

3 No articles reported cost-effectiveness analysis; 

interventions to be cost saving. 

Langhorne 2005219 Team coordination/delivery 11 Total costs estimated; median cost reduction in t

group of 20% (range 4-30). 

Higginson 2003220 Palliative care teams 14 Only one article reported the intervention as cost

remaining articles reported costs and resource usarticles were heterogeneous. 

Richards 2003222 Comprehensive discharge 

planning and implementation 

2 Both articles showed lower intervention costs. M

lower in one article (1989-1992 values) among thintervention ($8956.44 vs. $9262.20); average covalues) in the other article was significantly lowe($3630 vs. $6661) 

Neumeyer-Gromen 2004223 Disease management 6 Results from cost effectiveness/cost utility analy

from $9,051 to $48,500 per quality-adjusted life 

65
Table 13. Reviews with entire focus on care coordination: cost results (continued) 

Reference Intervention No. of articles 

reporting cost 

data 

Results 

Whellan 2005226 Disease management 10 5 of the articles reported significantly lower inter

usual care; one reported significantly higher inte4 reported no difference between the two groups

Yu 2005227 Disease management 11 8 effective and one ineffective disease managem

costs per case; one effective and one ineffective program reported no significant differences in co

Krause 2005229 Disease management 67 Overall, disease management programs were eco

size 0.311 (95% CI: 0.272-0.35)]. 

Gorey 1998231 Case management 6 5 of the 6 articles reported lower intervention coMarshall 1998232 Case management 6 The cost data reported in the articles were insuffi

any definitive conclusions. 

Windham 2003233 Care management 17 6 articles showed significant reduction in interve

control group; 6 found no difference; 5 did not re

Briggs 2006236 Integration of services 2 Inconclusive evidence of integration on cost imp

per patient to be higher for usual care; the other abe less costly. 

Philbin 1999241 Comprehensive, multidisciplinary 

program 

3 2 articles reported decreased costs in the interven

were associated with decreased hospitalizations. 

evidence. 

Gruen 2003245 Specialist outreach clinics 4 Cost per patient. 2 articles found the intervention 

and $296 respectively) more per patient); howevreported their intervention to be 7.4% more cost-outcomes were considered. 2 articles reported lopence and AUD$173 respectively) 

Mitchell 2002247 Organised cooperation 2 Cost results were mixed. 

66
67 

Given the heterogeneity of the included reviews, we did a separate synthesis for selected care 

coordination strategies, clinical topics, vulnerable populations, and across settings. We report 

the results of our narrative synthesis in the following sections; the synthesis includes reviews that 

focused entirely on care coordination and where possible, those that focused partially on care 

coordination. 

Narrative Syntheses of Selected Systematic Reviews by Care 

Coordination Strategy 

We identified five care coordination strategies that were reported in more than one 

systematic review: use of teams (usually multidisciplinary), case management, disease 

management, integrated care, and interprofessional education. Thus, we were able to provide a 

narrative synthesis of the evidence on each of these care coordination strategies. 

Systematic Reviews Evaluating Multidisciplinary Teams as a Care 

Coordination Strategy 

Background. Multidisciplinary teams usually involve two or more providers from different 

specialties providing care to a group of patients. Presumably, teams consisting of health care 

personnel from different fields are more likely to address all the components of patient care, are 

more likely to share information and thereby, provide more coordinated care. Interventions that 

involve the use of multidisciplinary teams in managing a patient’s care may be associated with 

better outcomes.217 

Results. Among the reviews that focused entirely on care coordination, we found 15 

reviews208-222 that evaluated the effects of multidisciplinary teams (Table 14a, Table 14b, Table 

14g, Table 14i, Table 14j); among the reviews that partially focused on care coordination, 11249-

259 included multidisciplinary teams as part of their interventions (Table 15). 

Mental Health. Two systematic reviews212, 215 examined the effect of assertive community 

treatment for patients with severe mental disorders (Table 14a). Assertive community treatment 

(ACT) has been defined as an approach to providing care that is characterized by a 

multidisciplinary team who care exclusively for a group of patients and share responsibility for 

their patients; it emphasizes team work and coordination of activities. Marshall and 

Lockwood212 included 26 articles in their review of severely mentally ill patients, and found 

significantly improved outcomes for patients receiving ACT when compared to standard care, or 

hospital-based rehabilitation. Patients receiving ACT were less likely to be admitted to a 

hospital [0.59 (0.41-0.85)], be unemployed [0.31 (0.17-0.57)], or become homeless [0.24 (0.08-

0.65)]. They were also more likely to remain in contact with services [OR: 0.51 (95% CI: 0.37-

0.70)], and more likely to be living independently [0.46 (0.25-0.86)] when compared to standard 

care. These findings were consistent when compared to hospital-based rehabilitation; there was 

insufficient data to allow comparison to case management. In their meta-analysis of 19 articles 

that compared ACT to usual treatment, Ziguras and Stuart215 found improved outcomes for 

assertive community treatment for severely mentally ill patients when compared to standard care 

(Table 14a). ACT had a significant positive effect on hospital days [Weighted mean r = 0.28 

(95% confidence interval 0.24-0.32), p<0.001]; clients receiving ACT were likely to have more 

contact with mental health services [0.18 (0.12-0.23), p<0.001); lower dropout rates from mental 
68 

health services [0.37 (0.27-0.46), p<0.001) and greater family satisfaction [0.46 (0.33-0.58), 

p<0.001). The review also found that both assertive community treatment and case management 

reduced hospitalization, but assertive community treatment was more effective in reducing 

hospitalization (p<0.001 for difference in effect sizes between the two groups). 

Gunn et al.210 also studied the effect of “system interventions” to improve recovery from 

depression (Table 14a). Their definition specifically included multidisciplinary teams and 

enhanced communication. They included eight trials that reported an increase in the proportion 

of patients recovering from depression in favor of the intervention group (range 10% to 33%); 

however the included studies did not account for attrition rates ranging from 5% to 50%. 

Wadhwa and Lavizzo-Mourey214 studied whether multidisciplinary teams and case 

management models improved care for patients with either mental or terminal illness. Neither of 

these interventions improved functional, clinical, or psychological outcomes; although 

multidisciplinary teams were effective in reducing hospitalizations among mentally ill patients 

(Table 14a). 

Craven and Bland209 evaluated the effectiveness of collaborative care for mental health; 

however, their definition of collaborative care includes health care professionals from different 

disciplines working together (Table 14a). The authors did not conduct a quantitative analysis, 

but provide data on each included study. They reported the following best practices for 

collaborative care: collaborative relationships at either a system-level or provider level require 

time, supportive structures and preparation; the degree of collaboration does not appear to predict 

outcomes; for collaboration to be effective, it should be paired with treatment guidelines; 

collaboration works best when clinicians and specialists are located in the same place; systematic 

followup was a strong predictor of positive clinical outcomes; patient choice about treatment 

may be important; and collaborative care interventions established as part of a research study 

may be difficult to sustain once the study is complete. Based on their review, it was not possible 

to evaluate the effectiveness of different elements of collaborative care. 

Crawford et al.252 reported their results of a review on providing continuity of care for 

patients with severe mental illness (Table 15). They included 60 articles identifying factors that 

either promoted or impeded the continuity of care among these patients; assertive community 

treatment and community mental health teams were among two of the care coordination 

strategies evaluated in some of the included articles. The authors categorized continuity of care 

as either longitudinal (continuity of care over a period of time, most likely characterized by the 

provision by a single provider) or cross-sectional (continuity of care between different services, 

characterized mostly by different providers or settings). Care coordination was an important 

component in the provision of care between primary and secondary services and between 

medical, social and other services. Unfortunately, most of the included articles did not define 

continuity of care and the articles addressing care coordination were limited to epidemiologic 

studies, nonrandomized trials and qualitative research. However, the review identified three 

meta-analyses of care coordination interventions, such as case management, assertive community 

treatment and community mental health teams (already included in our reviews that focused 

entirely on care coordination212, 213, 232), which suggested that the use of such interventions can 

decrease the likelihood that patients will lose contact with services. 

Heart Failure. McAlister et al.217 and Holland et al.216 both examined the effect of 

multidisciplinary teams on the management of heart failure patients (Table 14b). The review by 

Holland et al.216 was an update of the McAlister review, with nearly double the included studies; 

therefore, there was considerable overlap of the included studies between the two reviews. 
69 

McAlister et al.217 did not provide a definition of multidisciplinary teams; however, Holland et 

al.216 provided a clear definition. Both studies reported improvements in outcomes when 

interventions included multidisciplinary teams. McAlister et al.217 reported that follow-up by a 

specialized multidisciplinary team reduced mortality [risk ratio (RR) 0.75, (95% confidence 

interval (CI) 0.59-0.96)], and hospitalizations (heart failure hospitalizations: [0.74 (0.63-0.87)]; 

all-cause hospitalizations: [0.81 (0.71-0.92)] (Table 14b). Holland et al.216 reported similar 

results: multidisciplinary team interventions reduced all cause admission [RR: 0.87 (95% CI: 

0.79-0.95), p=0.002], all cause mortality [0.79 (0.69-0.92), p=0.002] and heart failure admission 

[0.7 (0.61-0.81), p<0.001]. Holland et al.216 also conducted subgroup analysis to determine the 

effect of setting and intensity. Interventions with a home-based component or those with 

telephone follow-up were more effective than those based in the hospital or clinic; home-based 

interventions showed reductions in both all cause [0.8 (0.71-0.89), p<0.0001] and heart failure 

[0.62 (0.51-0.74), p<0.001] admissions. Intensity of the intervention [high or low] and risk of 

the patient (high or low) did not appear to have an impact on effectiveness. It was not possible to 

evaluate the effect of specific intervention components; however, almost all the included 

interventions had two elements in common: symptom monitoring and self-management advice; 

and one-to-one patient education. 

Pain Management. Higginson et al.220 conducted a meta-regression and meta-analysis that 

included 44 articles to determine if palliative care teams improve patient outcomes and found 

significant improvements on patients’ pain [OR 0.38 (95% confidence interval 0.23-0.64)] and 

other symptoms [0.51 (0.30-0.88)] (Table 14h). 

Stroke. Langhorne et al.219 studied the effect of early supported discharge interventions 

among elderly stroke patients (Table 14j). They assessed whether team coordination and 

delivery (seven studies) or team coordination alone (two studies) had any effect on death or 

dependency in activities of daily living. They specifically examined the amount of effort that 

would be required by teams (staffing levels, case load) as well as how teams worked together 

(effect of weekly team meetings, an example of a coordinating process in one conceptual model 

on organizational theory described in Chapter 5). They found that coordination of teams through 

weekly team meetings were more effective in reducing the risk of death or dependency (OR: 

0.70, 95% CI: 0.56-0.88, p=0.02) compared to no team coordination (Table 14j). 

No Specific Clinical Focus. Lemieux-Charles and McGuire221 conducted a systematic review 

to study the overall effectiveness of health care teams for a general patient population (Table 

14k). They reported information on 12 studies evaluating the effectiveness of team versus no 

team interventions; nine studies evaluating team redesign interventions; and 12 multi-site field 

studies. The authors presented descriptions of the included studies and provided a narrative 

analysis. They suggested that the diversity and type of clinical expertise involved in team 

decisionmaking may account for improved patient care and organizational effectiveness. Some 

factors likely to influence staff satisfaction and perceived team effectiveness are: collaboration, 

conflict resolution, participation and cohesion. They also stated, however, that the existing 

evidence does not provide clear direction on how to design or maintain high-functioning teams. 

The lack of quantitative synthesis makes it difficult to evaluate their findings. 

Summary. Multidisciplinary teams have been shown to improve select patient outcomes in 

stroke, heart failure, severe mental illness, and terminal conditions. Specifically, the evidence 

suggests that among patients with mental illness, multidisciplinary teams can reduce 

hospitalizations and improve the rates with which clients remain in contact with services. 

Furthermore, in the clinical areas of heart failure and stroke, multidisciplinary teams can improve 
70 

mortality and dependency. Hospital admissions are also reduced by this intervention for heart 

failure patients. For patients needing palliative care, a team approach can reduce symptoms. 

The evidence also suggests that multidisciplinary teams are more effective when team members 

deliberately coordinate their activities (e.g., schedule regular team meetings to facilitate 

exchange of information).219

Systematic Reviews Evaluating Disease Management as a Care 

Coordination Strategy 

Background. In the reviews we identified, disease management has been defined in 

numerous ways and there does not appear to be a consensus from systematic reviewers about 

specific components that should be included in a disease management program. Disease 

management programs include the involvement of both patients and clinicians. The intent of all 

the disease management programs, however, is to improve the coordination of patient care, 

provide support to patients, and improve patient outcomes. 

Results. Among the reviews that focused entirely on care coordination, we found ten 

reviews152, 218, 223-230 (Tables 16a-k) that evaluated the effects of disease management; we found 

eight reviews148, 260-266 among those that focused partially on care coordination using a disease 

management approach (Table 15). 

Mental Health. Neumeyer-Gromen et al.223 conducted a meta-analysis of disease 

management programs for depression (10 included articles). Disease management programs 

when compared with usual primary care, significantly improved depression severity [RR 0.75 

(95% CI: 0.70-0.81)], adherence to treatment regimen [0.59 (0.46-0.75)] and patient [0.57 (0.37-

0.87)] and provider satisfaction. They also reported on the cost-effectiveness of disease 

management programs which were reported in six articles that were deemed high quality by the 

authors. The cost utility ratios (not defined by the review) per quality adjusted life years ranged 

from $9,051 to $49,500 (Table 14a). 

Heart Failure. We included four reviews224-227 that studied the effectiveness of disease 

management programs on improving outcomes for patients with heart failure (Table 14b). Three 

of the four reviews conducted meta-analyses of the included studies; there was considerable 

overlap of the included studies across all four reviews. Disease management was not welldefined by any of the reviews, though two reviews225, 227 provided extensive descriptions of the 

disease management programs reported in each included study. The meta-analysis by 

Roccoforte et al.225 found that disease management programs significantly reduced mortality 

[OR: 0.8 (95% CI: 0.69-0.93), p=0.003], all-cause re-admission rates [0.76 (0.69-0.94), p< 

0.00001] and HF-related admission rates [0.58 (0.5-0.67), p<0.00001] compared to usual care. 

They also conducted sensitivity analysis looking at type of care provider and duration of 

intervention. Type of care provider had an effect on outcomes: mortality was reduced in 

multidisciplinary interventions [0.58 (0.44-0.75)] but not in nurse-based only interventions [0.93 

(0.77-1.11]. Length of intervention had mixed results; long term interventions (> 6 months) 

appeared to reduce all outcomes; however, short-term (0-3 months) and medium term (3-6 

months) also reduced admission rates. Yu et al.227 categorized the disease management 

programs for heart failure patients into effective or ineffective on the basis of the characteristics 

for disease management programs recommended by the European Society of Cardiology (ESC). 

Effective programs (n=11) significantly decreased hospital readmissions by 29%-85% (mean 

44.15 +/- SD: 14.36%); four programs significantly reduced mortality rates by 28%-78% (57.6 
71 

+/- 21.9%). They also reported that effective disease management programs improved quality of 

life and were cost saving. When comparing specific components of the intervention, effective 

disease management programs had the following: multidisciplinary teams, or care that involved 

both a cardiac nurse and cardiologist; provided a wider range of in-hospital care; were more 

likely to include home visits; and ongoing surveillance and management. 

Diabetes. Knight et al.228 also studied the effectiveness of diabetes disease management 

programs and found a mean reduction in glycated hemoglobin of 0.5 (95% CI: 0.3-0.6) 

percentage points among disease management programs (Table 14c). They also reported that 

programs associated with the greatest decrease in glycated hemoglobin involved pharmacists 

counseling patients and combined physician and patient interventions. The specific components 

of the interventions were not reported by the review. 

Norris et al.152 studied the effectiveness of both disease management (27 articles) and case 

management (15 articles) on outcomes for patients with diabetes. They reported improvements 

in glycemic control [median net change: -0.5% (interquartile range: -1.35% to -0.1%)] and on 

screening for and monitoring of lipid concentrations [15.6% (4% to 39%)], dilated eye exams 

[9% (3% to 20%)] and foot exams [26.5% (10.9% to 54%)] among patients who received the 

disease management program. These improvements were applicable to adults with diabetes in 

both community clinics and managed care organizations in the U.S. and Europe (Table 14c). 

Multiple Clinical Focus. Krause229 examined economic outcomes of disease management 

programs (Table 14f). His meta-analysis included 67 studies on disease management programs 

for asthma, diabetes or heart failure. Overall, there was a positive effect on economic outcomes 

for disease management programs [effect size 0.311 (95% CI: 0.272-0.35)]. Program 

interventions were significantly different, with team-based interventions being the most 

effective: team-based [0.395 (0.32-0.47)], self-managed [0.916 (0.148-0.243)], and nurse-based 

[0.306 (0.253-0.359)]. Disease severity significantly affected economic outcomes of programs; 

interventions aimed at more severely and moderately ill patients were more effective than those 

aimed at patients with mixed severity [0.35 (0.306-0.396) versus 0.175 (0.142-0.208), 

respectively]. The effect on economic outcomes did not differ by disease type (asthma, diabetes 

or heart failure). 

Rheumatoid Arthritis. Badamgarav et al.230 evaluated the effects of disease management 

programs on the functional status of patients with rheumatoid arthritis (11 included articles). 

Overall, disease management did not improve functional status in patients with rheumatoid 

arthritis [Effect size: 0.27; 95% CI: -0.01-+0.54)]. The authors performed a sensitivity analysis 

to determine the effect of intervention intensity and duration. Interventions lasting longer than 5 

weeks showed significant improvements in patient functional status [0.49 (0.12-0.86)] compared 

with those lasting <= 5 weeks [0.13 (-0.25-0.52)]; the intensity of the intervention did not have a 

similar effect (Table 14i). 

Among the reviews that only partially focused on care coordination, eight included disease 

management programs (Table 15).148, 260-266 Even though the definition of disease management 

as provided by the authors did not indicate a clear care coordination component, we included 

these reviews because the intent of all the programs was to improve the coordination of care 

through a disease management program. Furthermore, the descriptions provided for the 

interventions of the included articles within the reviews suggested a care coordination element. 

The reviews included heterogeneous interventions. Five of the reviews148, 260, 261, 263, 264 reported 

an overall positive effect of disease management programs on outcomes. One review262 reported 

promising results in its study of disease management programs for congestive heart failure, 
72 

hypertension and hyperlipidemia-coronary artery disease. However, all of the reviews lacked a 

focused analysis on coordination-related activities and functions (e.g., clear definition, intensity, 

and structure). 

Summary. Disease management programs appear to be effective in improving depression 

severity and adherence to treatment in patients with mental illness, glycemic control in patient 

with diabetes and mortality and re-admission rates in patients with heart failure. However, the 

heterogeneity of the definitions of disease management and the limited analysis on the specific 

components that may contribute to the effectiveness of disease management programs makes it 

difficult to interpret the findings with respect to the overall effectiveness of care coordination. 

Some of the reviews suggest improved outcomes based on patient targeting, multi-disciplinary 

teams, home visits, ongoing monitoring, pharmacist counseling on medications, and other lesswell specified factors. 

Systematic Reviews Evaluating Case Management as a Care 

Coordination Strategy 

Background. Case management (also referred to as care management in some instances – 

particularly in the United Kingdom -- without any distinction in meaning) typically involves the 

assignment of a single person (case manager or “key worker”, so named in one study234) who 

coordinates all aspects of a patient’s care (e.g., providing information to multiple providers, 

seeing that the patient receives services in a timely manner etc.). The assumption behind case 

management is that having one person perform all the coordinating functions for a patient’s care 

is likely to lead to improved coordination and possibly better outcomes. 

Results. Among the reviews that focused entirely on care coordination, we found nine 

reviews152, 214, 215, 222, 231-235 (Tables 16a-k) that evaluated the effects of case management on 

patient outcomes; among those reviews that only partially focused on care coordination, 12249, 250, 

252, 254, 256, 257, 259, 267-271 (Table 15) included case management as part of their included 

interventions. 

Mental Health. Gorey et al.231 evaluated the effectiveness of case management in improving 

outcomes for mentally ill patients (24 articles). They found that case management was effective 

in reducing re-hospitalization (mean effect size r-index: 0.277, standard deviation: 0.235). They 

also analyzed characteristics of case management (e.g., case load) and found that patients 

receiving more intense case management (case load of less than 15 per case manager) were 30% 

less likely to be re-hospitalized (Table 14a). 

Wadhwa and Lavizzo-Mourey214 studied whether multidisciplinary teams and case 

management models improve care for patients with either mental or terminal illness. Their 

results suggested that aggressive case management may be beneficial to patients with mental 

illness; however, they only included one study of case management among patients with terminal 

cancer which did not report any significant differences between the intervention and control 

group with respect to functional, clinical, or psychological outcomes (Table 14a). 

Gilbody et al.269 conducted a systematic review to evaluate whether organizational and 

educational interventions improve management of depression in primary care (Table 15). Since 

they were unsuccessful in their attempt to identify active components of successful interventions, 

they provided examples of successful and unsuccessful strategies that improved outcomes such 

as treatment adherence, depression outcomes and improved uptake of therapy. Most of the 

effective strategies presented in the review included some elements of care coordination. These 
73 

were: collaborative care, defined as programs that included shared care among different care 

providers; stepped collaborative care, which included enhanced collaborative management by a 

psychiatrist in the primary care setting; quality improvement programs that included nurse case 

management and integration with specialist care; and case management, which was usually done 

by nurses and involved some element of follow up. 

Heart Failure. Windham et al.233 studied the effect of care management interventions for 

congestive heart failure among older patients (32 articles). The purpose of their review was to 

identify components of successful care management programs. They found that the key 

elements of an effective care management program (defined as a program in which most of the 

outcomes measured were significantly positive) included employing a physician and either a 

nurse or case manager to coordinate care; close monitoring and follow up of patients by nurses or 

case managers; and patient education combined with regular contact with a nurse or a physician 

(Table 14b). 

Diabetes. Norris et al.152 studied the effectiveness of both disease management (27 articles) 

and case management (15 articles) on outcomes for patients with diabetes. They reported 

improvements in glycemic control [median net change: -0.4% (interquartile range: -0.6% to 

-0.16%)] and provider monitoring in patients receiving case management. 

No Specific Clinical Focus. Payne et al.234 assessed the effectiveness of different methods of 

transferring information from the hospital to the community at the time of discharge in 31 

articles (Table 14k). Presumably, good and effective information transfer forms the basis for 

improved care coordination. They found that using a key worker to facilitate information 

transfer improved the quality of the information provided, improved patient and caregiver 

satisfaction and increased “patient concordance” with services; however, they were unable to 

report sufficient evidence as to the professional background of such a worker or where this 

person should be located (community or hospital). 

Summary. Case management as a care coordination strategy appears to improve patient 

outcomes for patients who have mental health problems, heart failure or diabetes. Among the 

included reviews, there was insufficient evidence to make a summary determination as to the 

training required for effective case managers (e.g., nurse, social worker, other provider), the ideal 

qualifications of effective case managers, and the specific duties that should be performed for 

case management to be effective. Close patient monitoring was identified as an important 

component in two reviews. 

Systematic Reviews Evaluating Integrated Care as a Care 

Coordination Strategy 

Background. Integration of patient services either across diseases or between providers may 

improve care coordination. In both situations, health personnel work closely together and have 

the opportunity to share information, which should lead to improved coordination. The reviews 

included here focused on integrating care programs as an approach to improving care 

coordination. 

Results. Among reviews that focused entirely on care coordination, we identified three235-237

that evaluated the effectiveness of integrated care programs (Tables 16a, 16k). Jeffery et al.235

studied the effect of integrating services for patients with mental illness and substance misuse 

(offering treatment to address both problems in a single location) (Table 14a). Briggs et al.236

studied integration of primary care services (bring together different types of services, for 
74 

example, packaging together services around a particular set of needs such as sexually 

transmitted disease services integrated with provision of contraceptives and/or family planning) 

(Table 14k). Both reviews found a lack of evidence regarding any clear benefit or harm from 

integrating services. 

Johri et al.237 reported a narrative synthesis of seven successful integrated care programs that 

provided care to the elderly (Table 14k). They did not summarize their findings but instead 

reported the key elements that were common across the seven programs. However, since they 

only reported on the successful programs and did not provide information on unsuccessful 

programs, it is difficult to analyze the effectiveness of integrated care programs from their 

review. 

Summary. There is insufficient evidence to either support or refute the effectiveness of 

integrated care programs. 

Systematic Reviews Evaluating Interprofessional Education as a Care 

Coordination Strategy 

Background: Interprofessional education is defined as the provision of training and 

education to professionals from different health and social areas, who learn together 

interactively. The aim of interprofessional education is to improve the coordination of patient 

care by improving the way professionals collaborate with each other. We considered this a care 

coordination strategy since it is an approach to improving patient care through improved 

coordination among multiple providers. 

Results. Among the reviews that focused entirely on care coordination, we identified three 

reviews238-240 that evaluated the usefulness of interprofessional education. Zwarenstein et al.240

were unable to find any articles of methodological rigor that met their inclusion criteria (Table 

14k). Reeves238 extended the work by Zwarenstein et al.240 by broadening the inclusion criteria 

to articles of all study designs. His review concluded that the evidence relating to the 

effectiveness of interprofessional education was “patchy” (Table 14a). Irajpour et al.239 found 

that the evidence was “broadly supportive” of interprofessional education, but was insufficient to 

determine the best way to improve pain management (Table 14g). 

Summary. There is insufficient evidence to determine the effectiveness of interprofessional 

education in improving collaboration among professionals. 

Narrative Syntheses of Systematic Reviews by Selected 

Clinical Topic, Population, and Setting 

Systematic Reviews of Care Coordination Strategies Among Patients 

With Mental Health Problems 

Among our included reviews that focused entirely on care coordination, we found that care 

coordination interventions were most often studied among patients with mental health problems 

(mental illness, severe mental illness, depression). These patients are more likely to require 

complex care and services across different areas, thereby putting them at higher risk for poorly 

coordinated care. Among reviews that focused entirely on care coordination, we identified 13 

reviews that focused on patients with mental health problems (Table 14a); among reviews that 
75 

focused only partially on care coordination, we identified 15 reviews251, 252, 254-256, 258, 261, 263-266, 

269, 270, 272, 273 that included patients with mental health problems (Table 15). A variety of 

different care coordination strategies were evaluated among this population: multidisciplinary 

teams, assertive community treatment, case management, collaborative care, disease 

management, integrated care programs and interprofessional education. Most of the reviews 

reported improved outcomes within each strategy studied. Several reviews compared different 

types of intervention, and no single strategy appeared to be more effective than other strategies. 

Since the interventions were not always described in enough detail, we are unable to draw any 

firm conclusions, but it appeared that strategies that included a more intense approach and 

involved community outreach (e.g., assertive community treatment, community mental health 

teams) were associated with positive outcomes, including better contact with services, fewer 

suicides, and reduced hospitalizations (or days hospitalized). Given the heterogeneity of the 

strategies studied and the lack of evidence pointing toward the success of one strategy over 

another, we were limited in our ability to interpret the findings with respect to the comparative 

effectiveness of any particular strategy for improving outcomes among patients with mental 

health problems. 

Systematic Reviews of Care Coordination Strategies Among Patients 

With Heart Failure 

Among our included reviews that focused entirely on care coordination, we found nine 

reviews that focused on patients with heart failure or heart disease (Table 14b); among reviews 

that focused partially on care coordination, we identified five reviews250, 260, 262, 268, 270 that 

included patients with heart failure (Table 15). Multidisciplinary teams and disease management 

were the two main care coordination interventions evaluated in these reviews. Four reviews224-

227 reported reductions in either readmission rates or mortality associated with disease 

management programs; four reviews216-218, 241 also reported the effectiveness of multidisciplinary 

teams in reducing readmission rates or mortality. However, there was considerable overlap of 

the included studies across these reviews. Holland et al.216 reported significant reductions in allcause admission, all-cause mortality and heart failure admission in interventions with 

multidisciplinary teams. They also reported that interventions with a home-based component or 

telephone follow-up were more effective than those based in the hospital or a clinic. Intervention 

intensity and patient risk did not have an impact on effectiveness. Roccoforte et al.225 reported 

that disease management programs were also associated with reductions in mortality, and allcause and heart failure readmission rates; additionally, mortality was significantly reduced in 

interventions provided by multidisciplinary teams but not in nurse-based only interventions. 

Length of intervention did not appear to have an impact on effectiveness. Our findings suggest 

that multidisciplinary teams and disease management programs are associated with improved 

outcomes for patients with heart failure. However, it is unclear what components of the 

interventions contribute toward this improvement since the findings regarding intensity of 

intervention were mixed and there was insufficient analysis on specific intervention components. 

Furthermore, most of the reviews did not provide a clear definition of the care coordination 

intervention. Although some specific components of multidisciplinary teams and disease 

management programs that were associated with positive outcomes were described in some of 

the reviews, further research is needed to assess relative contributions of these components for 

improving outcomes among patients with heart failure or heart disease. 
76 

Systematic Reviews of Care Coordination Strategies Among Patients 

With Diabetes 

Among our included reviews that focused entirely on care coordination, we found only three 

reviews that included patients with diabetes (Table 14c); among our reviews that focused 

partially on care coordination, we identified four reviews148, 254, 271, 274 that included patients with 

diabetes (Table 15). One review evaluated the effectiveness of disease management and case 

management on diabetes outcomes and care.152 Norris et al.152 found that both disease 

management and case management improved glycemic control (Table 14c); disease management 

also improved screening and monitoring of selected outcomes associated with diabetes; one 

review evaluated the effectiveness of diabetes disease management programs;228 and the third 

review focused on identifying factors that contributed to the success or failure of shared care 

where care of the patient was shared by a general practitioner and a specialist.242 Given the 

heterogeneity of the care coordination strategies evaluated and the few studies evaluating care 

coordination strategies for diabetes care, we are limited in our ability to synthesize the evidence 

and draw any definitive conclusions about the comparative effectiveness of different 

coordination strategies in improving outcomes among patients with diabetes. However, disease 

management and case management both showed improved outcomes, including reductions in 

glycated hemoglobin. 

The remaining clinical areas (stroke, rheumatoid arthritis, asthma, pain management, and 

palliative care) were each studied in a single systematic review and so were not further 

synthesized. 

Systematic Reviews of Care Coordination Strategies Among 

Elderly Patients 

Elderly patients are likely to have co-morbid conditions with poorly coordinated care and 

constitute a vulnerable population that we were interested in. Among the reviews that focused 

entirely on care coordination, we identified eight219, 222, 227, 233, 234, 237, 241, 246 that included articles 

on care coordination strategies to improve care for elderly patients (Tables 16a-k). Three studies 

focused on heart failure patients, and one on stroke patients. The remaining four did not have a 

specific clinical focus. An assortment of care coordination strategies were evaluated (e.g., 

multidisciplinary teams, case management, disease management, geriatric assessment and 

evaluation) in these reviews, and most reported improved outcomes associated with each 

individual strategy studied. Overall, the results indicate that the use of care coordination 

strategies may improve outcomes among elderly patients (particularly reduction in hospital 

admissions); however, the heterogeneity of the included strategies do not permit any further 

synthesis that would allow us to assess the effectiveness of one particular strategy over another. 

Systematic Reviews of Care Coordination Strategies Across Settings 

When patient care is provided across different settings (e.g., discharge from the hospital or 

emergency department, patients are referred by primary care physicians for specialist care), it is 

possible for the care to be poorly coordinated. The transition of patient care from one setting to 

another constitutes another area we were interested in. Among the reviews that focused entirely 

on care coordination, we identified 12 reviews that studied different interventions specifically 
77 

aimed to improve patient care across settings. Four reviews242, 244, 245, 247 evaluated the 

effectiveness of interventions that linked primary care with specialist care. Greenhalgh242

evaluated the effect of shared care between general practitioners and specialists for patients with 

diabetes and reported the common elements of successful shared care programs (Table 14c). 

Mitchell et al.247 evaluated the effect of a introducing a formalized arrangement to link general 

practitioners with specialists which they referred to as organized cooperation (Table 14k). They 

reported mixed success for physical and functional health outcomes and a modest benefit of this 

intervention for some chronic mental health conditions. Gruen et al.245 studied the effects of 

regular, planned visits by a specialist practitioner from a usual location to a primary care or rural 

setting, a multifaceted outreach that involved increased collaboration between primary care 

providers and specialists. They found that this type of specialist outreach can improve measures 

of access (decreased cost, distance and travel time for patients), attendance to clinics, quality of 

care (guideline-concordant care and adherence to treatment) and health outcomes (Table 14k). 

Grimshaw et al.244 studied interventions to improve referrals from primary care to specialists and 

reported that such improvements may occur if guidelines for referrals are distributed with 

standard forms and involve consultants in education, or if a second opinion or enhanced services 

are provided before a referral (Table 14k). There was insufficient evidence to determine which 

intervention is effective in linking primary care with specialist care. 

Three reviews235-237 evaluated the effect of integrating services received by patients in 

different settings into one setting (Tables 16a, 16k). The evidence was insufficient to determine 

the effectiveness of this strategy in improving patient care. 

Four reviews219, 222, 234, 246 studied different interventions aimed at improving discharge 

planning for patients from hospital or the emergency department to reduce future readmissions. 

Langhorne et al.219 reported the effectiveness of multidisciplinary teams in reducing death or 

dependency, for patients who had a stroke, when coordinating discharge from the hospital and 

providing post-discharge care and rehabilitation at home (Table 14j). McCusker246 and 

Richards222 both evaluated the use of comprehensive geriatric assessment and evaluation. 

Richards222 found limited evidence that implementation of care plans after discharge was 

effective. McCusker246 reported that interventions with greater integration with primary medical 

care were effective (Table 14k). Payne et al.234 studied current methods for transfer of patient 

information at discharge and found them to be inadequate (Table 14k). They also reported 

insufficient evidence to determine where key workers, who can facilitate information transfer, 

should be located or what their professional qualifications should be. There was insufficient 

evidence to determine the effectiveness of a specific intervention in improving discharge 

planning to reduce future admissions. 

One review192 aimed at reducing disparities in cancer care by addressing barriers to care. 

The authors evaluated whether navigation programs reduce barriers. The review reports 

descriptions of 11 navigation programs to reduce barriers to cancer care and distinguish between 

the types of personnel who serve as navigators. There is limited data evaluating whether these 

programs address barriers; the existing literature "suggests that navigation is associated with 

improved rates of screening and follow-up, lower clinical stage of presentation, and higher 

patient satisfaction." There is also some indication that "navigation services improve the clinic's 

ability to engage, track, and support patients and to develop communication and trust between 

clinics and disadvantaged populations." (Table 14k) 

In summary, the reviews studying transition of patient care across different settings evaluated 

a wide variety of interventions. The included interventions were not clearly defined in most of 
78 

the reviews and only one review provided clear evidence of the effectiveness of its intervention 

(multidisciplinary teams for hospital discharge and post-discharge of stroke patients). The 

heterogeneity of the included interventions and the lack of quantitative analysis do not permit 

any further synthesis that would allow us to determine the effectiveness of any particular care 

coordination intervention to improve patient care across settings. 
Table 14a. Summary of reviews with entire focus on care coordination interventions: mental health 

Reference Purpose Care coordination intervention and 

definition 

No. of 

articles 

Results 

Bower 2000208

To assess the effect on primary care provider behavior of adding an onsite mental health worker 

On-site mental health worker: services provided by an on-site MHW were a separate activity and not part of normal primary care consultations; the PCP and MHW work for at least part of the time as part of the same clinical team

38 The addition of a mental health worker to the pri

team did not have any significant effects on provbehavior. The evidence did not support the addmental health worker to a primary care team with of changing provider behavior. 

Craven 2006209

To identify better practices in collaborative care for mental health 

Collaborative care: "involves providers from different specialties, disciplines, or sectors working together to offer complementary services and mutual support, to ensure individuals receive the most appropriate service from the most appropriate provider in the most suitable location, as quickly as necessary, with a minimum of obstacles. Collaboration can involve better communication, closer personal contacts, sharing of clinical care, joint educational programs, and (or) joint program and system planning."

38 The authors reported the following results: colla

relationships at either a system-level or provider require time, supportive structures and preparatiodegree of collaboration does not appear to predicfor collaboration to be effective, it should be pairtreatment guidelines; collaboration works best wclinicians and specialists are located in the same systematic follow-up was a strong predictor of pclinical outcomes; patient choice about treatmenimportant; and collaborative care interventions eas part of a research study may be difficult to susthe study is complete. 

Gunn 2006210

To assess effectiveness of “system level” interventions for depression 

System level interventions: had to include ALL of the following: (1) multiprofessional approach with a GP and at least one other health professional; (2) a structured management plan; (3) scheduled patient follow up; (4) enhanced interprofessional communication through 

team meetings, case-conferences, feedback between care-givers

11 Eight articles reported an increase in the proport

patients recovering from depression in favor of tintervention group (range 10% to 33%); howevedid not account for attrition rates ranging from 5

Latimer 1999211

To determine the economic impacts of the assertive community treatment model 

Assertive community treatment: "involvement of team medical personnel along with a case manager, team meetings to discuss treatment plans”

34 The most consistent effect of the assertive comm

treatment (ACT) model was the greater reduction use, particularly of programs that have higher fidACT model. "Based on costs in Quebec, high-fidcan cut costs if patients averaged more than abouhospitalization yearly". 

79
Table 14a. Summary of reviews with entire focus on care coordination interventions: mental health (continued) 

Reference Purpose Care coordination intervention and 

definition 

No. of 

articles 

Results 

Marshall 2000212

To determine the effectiveness of assertive community treatment (ACT) for severe mental disorders when compared to standard care, hospital-based rehabilitation and case management 

Assertive community treatment: a 

multidisciplinary team sharing responsibility for their patients who care exclusively for a group of patients; emphasizes team working and responsibility 

26 Patients receiving ACT were more likely to rema

contact with services [OR: 0.51 (95% CI: 0.37-0less likely to be admitted to a hospital [0.59 (0.4more likely to be living independently [0.46 (0.2less likely to become homeless [0.24 (0.08-0.65)likely to be unemployed [0.31 (0.17-0.57)] when to standard community care. These findings werconsistent when compared to hospital-based reha

There was insufficient data to allow for comparimanagement for patients remaining in contact wand hospitalization. There was insufficient cost however, limited data suggests that ACT programexpensive. Overall, the evidence suggested that effective in caring for mentally ill patients in the community. 

Simmonds 2001213

To assess the benefits of community mental health team management in severe mental illness 

Community mental health team management: generic care (care not supplemented by assertive community treatment, intensive case management or other specific model) from a communitybased multi-disciplinary team that provides a full range of interventions

5 Community mental health team management com

standard care was associated with fewer deaths bor suspicious circumstances, lesser loss to followreduced hospital stay, and reduced costs. The inshowed no impact on social functioning. 

Wadhwa 1999214

Do multidisciplinary teams, case management, and outreach or home care improve the quality of care for vulnerable populations 

Multidisciplinary teams: “comprehensive care is delivered through the coordinated action of a diverse collection of health care populations” Case management: “a health care professional who works with the patient and families” 

3 6 

These interventions did not consistently demonsimprovements in functional, clinical or psycholooutcomes. Multidisciplinary outreach strategies effective in reducing in-patient hospitalizations amentally ill patients. Aggressive case managemalso appeared to be beneficial to mentally ill patiSatisfaction among patients and care givers was among these interventions. There was insufficiedata provided in the articles. 

80
Table 14a. Summary of reviews with entire focus on care coordination interventions: mental health (continued) 

Reference Purpose Care coordination intervention and 

definition 

No. of 

articles 

Results 

Ziguras 2000215

To evaluate the effectiveness of case management in mental health 

Assertive community treatment: authors 

recorded the definition provided in each articleClinical case management: no specific definition; authors recorded the definition provided in each article. 

28 16 

Both assertive community treatment and clinical management had positive effects on family burdsatisfaction and costs of care. While clinical casmanagement increased total number of admissiodecreased the total length of stay in the hospital. with assertive community treatment the total numadmissions and the proportion of clients hospitalreduced. Overall, assertive community treatmeneffective in reducing hospitalization compared to case management. 

NeumeyerGromen 2004223

To assess the effectiveness and cost-effectiveness of disease management programs for depression 

Disease management: the program had to include all the following components: patient self management education, provider education, collaborative care, routine reporting and regular feedback between different professions, interdisciplinary discussion of treatment options and supervision by specialists

10 Disease management programs (DMPs) when co

with usual primary care, significantly improved 

severity [RR 0.75 (95% CI: 0.70-0.81)], adherentreatment regimen [0.59 (0.46-0.75)] and patient (0.37-0.87)] and provider satisfaction. This findapplicable across different degrees of depressionand US populations. DMPs can be considered ceffective (costs per QUALY: $9,051 to $49,500)effectiveness of single elements within the progrnot be assessed since the research question aimeanswering the effectiveness of DMPs which inclcomponents in a comprehensive care strategy. 

Gorey 1998231

To assess the effectiveness of case management for mentally ill patients 

Case management: "outreach, identification, assessment and service 

planning, service linkage and monitoring, 

advocacy"

24 Among articles assessing functional status, preve

re-hospitalization and quality of life, approximatquarters of patients in a case management prograbetter outcomes than those not in such programsapproximately three-quarters of case managed cacost less than the average comparison care plan. accounted for half of the variability observed in management's effectiveness. 

81
Table 14a. Summary of reviews with entire focus on care coordination interventions: mental health (continued) 

Reference Purpose Care coordination intervention and 

definition 

No. of 

articles 

Results 

Marshall 1998232

To assess the effectiveness of case management "as an approach to caring for severely mentally ill people in the community" 

Case management: "means of coordinating services"; by a single case manager who is expected to assess that person's needs, develop a care plan, arrange for suitable care to be provided, monitor the quality of the care provided, and maintain contact with the person

11 Patients receiving case management were more l

remain in contact with psychiatric services, thoueffect size was small. Case management approxdoubled the rate of hospital admissions when comstandard care. In one trial, case management fousignificant increase in medication compliance, oappeared unlikely that case management showed substantial improvement in clinical or social outThe effect of case management on costs must be interpreted with caution; while it appears that camanagement increases costs to health care provimay reduce cost to society. Overall, the authors that case management is a poor alternative to sta"because a small advantage in numbers remaininoff-set by a large increase in admission rates, no clinical gains and considerable uncertainty over 

Jeffery 2000235

To evaluate the effectiveness of different approaches to treating patients with problems of severe mental illness and substance misuse 

Integrated care programs: programs where substance misuse treatment was integrated with psychiatric care and care was provided by the same personnel teamCase management: not defined but included a specialized five-hour per week substance misuse treatment group 

6 1 

The review looked at complex patients: patients severe mental illness who also had problems witsubstance misuse. There was no clear evidence integrated programs have different outcomes comprograms providing psychiatric treatment alone. also no evidence that any particular type of integprogram was better than the others studied. Howarticle found that a residential integrated program likely to retain patients than a non-residential proOverall, there was no clear evidence that integrapatients with substance misuse and severe mentacan lead to better or worse outcomes. 

Reeves 2001238

To assess the effect of interprofessional education on the care of adults with mental health problems 

Interprofessional education: "when two or more professionals learn interactively together with the object of promoting collaborative practice"

19 All of the articles showed an improvement in the 

studied regarding provider education; however thnotes that the quality of the included articles was poor and so the evidence relating to the effectiveinterprofessional education can be considered "p

82
Table 14b. Summary of reviews with entire focus on care coordination interventions: heart failure 

Reference Purpose Care coordination intervention and 

definition 

No. of 

articles

Results 

Holland 2005216

To determine the effectiveness of multidisciplinary interventions on improving outcomes for patients with heart failure 

Multidisciplinary interventions:interventions "in which management was the responsibility of a multidisciplinary team that included medical input plus one or more of the following: a specialist nurse, a pharmacist, a health educator, a dietician, or a social worker"

30 Multidisciplinary interventions reduced all outc

reported: all cause admission [RR: 0.87 (95% Cp=0.002], all cause mortality [0.79 (0.69-0.92), heart failure admission [0.7 (0.61-0.81), p<0.00Interventions with a home-based component or telephone followup were more effective than ththe hospital or clinic; home-based interventions reductions in both all cause [0.8 (0.71-0.89), p<heart failure [0.62 (0.51-0.74), p<0.001] admissIntensity of the intervention [high or low] and rpatient (high or low) did not appear to have an ieffectiveness. Almost all included interventions elements in common: symptom monitoring and management advice; and one-to-one patient edu

McAlister 2004217

Do multidisciplinary strategies improve outcomes for patients with heart failure? 

Multidisciplinary heart failure clinic: not defined Multidisciplinary team providing specialized follow-up in a non-clinic setting: not defined 

7 8 

Specialized follow-up by multidisciplinary teamof setting), was associated with significant redu

cause mortality [RR: 0.75 (95% CI: 0.59-0.96)]hospitalization [0.81 (0.71-0.92)] and heart failuhospitalization rates [0.74 (0.63-0.87)]. The authat the following 3 elements were crucial to ththese programs: specially trained heart failure nand caregiver education, ready access to providheart failure. 

McAlister 2001218

To determine the effects of multidisciplinary disease management programs on outcomes among patients with coronary heart disease 

Multidisciplinary disease management: Programs using multidisciplinary teams and specialized clinics 

12 Multidisciplinary disease management program

compared to usual care showed reduced rate of hospital [RR 0.84 (95% CI: 0.76-0.94)] and lenstay. There was no effect on recurrent myocardor all cause mortality. Intervention patients weto be prescribed appropriate medications. 5 of 7 evaluating the impact of disease management ocardiovascular risk factors (reduction in cholestconcentration, rates of smoking cessation, reducpressure) showed significantly greater improvemintervention group. 5 of 8 trials measuring quashowed better improvements in the intervention 3 were statistically significant. 

83
Table 14b. Summary of reviews with entire focus on care coordination interventions: heart failure (continued) 

Reference Purpose Care coordination intervention 

and definition 

No. of 

articles

Results 

Göhler 2006224

To determine the efficacy of disease management programs for heart failure 

Disease management programs: 

No 

clear definition provided by review

36 Disease management programs (DMP) significantly 

cause mortality [Risk Difference: 3% (95% CI: 1%-5and all-cause hospitalization [8% (5%-11%), p<0.00Heterogeneity across the studies was explained by tecomposition (single person versus multiple persons)mode (personal contact versus telephone), patient agof disease and length of followup. 

Roccoforte 2005225

To evaluate the effectiveness of disease management programs for heart failure 

Comprehensive disease management programs: not defined by review

33 Disease management programs showed significant r

mortality [OR: 0.8 (95% CI: 0.69-0.93), p=0.003], aadmission rates [0.76 (0.69-0.94), p< 0.00001] and Hadmission rates [0.58 (0.5-0.67), p<0.00001] comparcare. Mortality was reduced in multidisciplinary int[0.58 (0.44-0.75)] but not in nurse-based only interv(0.77-1.11]; however, there was no difference in admbased on provider type. Length of intervention had mlong term interventions (> 6 months) appeared to redoutcomes; however, short-term (0-3 months) and me6 months) also reduced admission rates. 

Whellan 2005226

To evaluate the effectiveness of disease management programs for heart failure 

Disease management programs: not defined by review

19 Disease management programs showed a significant 

all-cause hospitalization; there was significant heteroresults. 

84
Table 14b. Summary of reviews with entire focus on care coordination interventions: heart failure (continued) 

Reference Purpose Care coordination intervention 

and definition 

No. of 

articles

Results 

Yu 2006227 To identify key 

components of effective disease management programs 

Disease management program (DMP): program "used multiple interventions in a systematic manner to manage heart failure across health-care delivery systems"

21 Categorized disease management programs into effe

ineffective using the characteristics recommended by Society of Cardiology (ESC). Effective programs (nsignificantly decreased hospital readmissions by 29%44.15 +/- SD: 14.36%); four programs significantly mortality rates by 28%-78% (57.6 +/- 21.9%). Effecimproved quality of life and were cost saving. When specific components of the intervention, effective DMfollowing: multidisciplinary teams, or care that invocardiac nurse and cardiologist; provided a wider ranghospital care; were more likely to include home visitongoing surveillance and management. 

Windham 2003233

“To identify those interventions and outcome measures that should be included when designing and assessing the effectiveness of care management programs for older patients with congestive heart failure” 

Care management programs: not 

defined by review

32 Characteristics of effective programs: close monitor

by nurses or care managers; patient education combiregular contact with nurse or physician. Characteristics of Ineffective programs: lack of struc

monitoring; self management alone without follow umonitoring; problems with patient selection; lack of standardized intervention; insufficient training of pe

Philbin 1999241

to evaluate the impact of

comprehensive, multidisciplinary management programs on outcomes and processes of care in patients with congestive 

heart failure 

Comprehensive, multidisciplinary program: not defined 

7 A decrease of 50% to 85% in the rate of hospital adm

reported in 6 articles. Improved functional status, aeor satisfaction was reported in five articles. The ecowas weak suggesting that multidisciplinary programsaving. 

85
Table 14c. Summary of reviews with entire focus on care coordination interventions: diabetes 

Reference Purpose Care coordination intervention and 

definition 

No. of 

articles

Results 

Knight 2005228

To determine the effectiveness of diabetes disease management programs 

Disease management: “an approach to patient care that coordinates medical resources for patients across the entire health care delivery system”

24 There was a mean reduction in GHb of 0.5 (95

0.6) percentage points among disease managemprograms. Those programs associated with gredecrease involved pharmacist counseling patiencombined physician and patient interventions. 

Norris 2002152

To examine the effectiveness of disease management and case management on diabetes outcomes and care 

Disease management: "organized, 

proactive multicomponent approach to healthcare delivery...care is focused on and integrated across the entire spectrum of disease and its complications, the prevention of comorbid conditions, and the relevant aspects of the delivery system"Case management: "a set of activities whereby the needs of populations of patients at risk for excessive resource utilization, poor outcomes or poor coordination of services are identified and addressed through improved planning, coordination and provision of care"

27 15 

There was an improvement in GHb among both management [median net change: -0.5% (interqrange: -1.35% to -0.1%)] and case managemen0.06% to -0.16%)] interventions. The case maninterventions showed similar improvements in implemented with or without disease manageminterventions. Disease management showed imin provider screening and monitoring of selecte(foot lesions, peripheral neuropathy, lipid concproteinuria, GHb and retinopathy). There was idata to estimate the economic effects of the intThe findings for disease management are applimanaged care and community settings in the UEurope; findings for case management can only to a US managed care setting. 

Greenhalgh 1994242

To determine factors that contributed to the success or failure of shared care for diabetes 

Shared care: care of patients is shared between a general practitioner and a specialist; care is characterized by enhanced information and exchange

24 Shared care that is structured and supported by 

team of general practitioners and specialists procomparable levels of care to that provided in hSuccessful shared care programs appear to havfollowing common elements: tailoring of the shprogram to the needs and resources identified atrained and experienced liaison nurse whose roserve as a coordinator and facilitator in the pro

GHb: glycated hemoglobin 

86
Table 14d. Summary of reviews with entire focus on care coordination interventions: asthma 

Reference Purpose Care coordination intervention and 

definition 

No. of 

articles

Results 

Ram 2005243

To assess the effectiveness of organized asthma care through primary care based asthma clinics 

Organized asthma clinics: clinics are nurse-led and usually doctor supported

1 There was limited evidence from one article th

asthma clinics can improve certain outcomes (ppeak flow meters; reduction in waking at night attack). 

Table 14e. Summary of reviews with entire focus on care coordination interventions: cancer 

Reference Purpose Care coordination intervention and 

definition 

No. of 

articles

Results 

Dohan 2005192

To assess if navigation programs reduce barriers to disparities in cancer care 

Navigation program: Not clearly 

defined; program aimed at reducing disparities in cancer care by addressing barriers 

62 The review reports descriptions of 11 navigation p

reduce barriers to cancer care and distinguish betw

types of personnel who serve as navigators. There data evaluating whether these programs address baexisting literature "suggests that navigation is assoimproved rates of screening and follow-up, lower of presentation, and higher patient satisfaction." T

some indication that "navigation services improve ability to engage, track, and support patients and to communication and trust between clinics and disadpopulations." 

87
Table 14f. Summary of reviews with entire focus on care coordination interventions: multiple clinical topics 

Reference Purpose Care coordination intervention and 

definition 

No. of 

articles

Results 

Krause 2005229

To determine the economic effectiveness of disease management programs 

Disease management: "a system of coordinated health interventions and communications for populations with conditions in which patient self-care efforts are significant"

67 Overall, disease management programs had positive 

outcomes [effect size 0.311 (95% CI: 0.272-0.35)]. interventions were significantly different with team-interventions being the most effective; self-managed (0.148-0.243)], nurse-based [0.306 (0.253-0.359)] anbased [0.395 (0.32-0.47)]. Disease severity significaeconomic outcomes; interventions aimed at more sev

moderately ill patients were more effective than thospatients with mixed severity [0.35 (0.306-0.396) vs 00.208), respectively]. Effect on economic did not didisease type (asthma, diabetes or heart failure). 

Table 14g. Summary of reviews with entire focus on care coordination interventions: pain management 

Reference Purpose Care coordination intervention and 

definition 

No. of 

articles

Results 

Irajpour 2006239

To determine if interprofessional education changes provider practice and patient outcomes 

Interprofessional education: “Occasions when two or more professions learn from and about each other to improve collaboration and the quality of care” 

4 Only one study reported improvement in patien

(p<0.0001) between the intervention and controtwo studies reported no difference in pain scorereported improvement in documentation of pain between groups (p<0.001). 

88
Table 14h. Summary of reviews with entire focus on care coordination interventions: palliative care 

Reference Purpose Care coordination intervention and 

definition 

No. of 

articles

Results 

Higginson 2003220

To determine the effectiveness of palliative care teams on patient outcomes 

Palliative care teams: "two or more health care workers, at least one of whom had specialist training or worked principally in palliative or hospice care"

44 Palliative care teams showed a significant improve

[OR 0.38 (95% CI: 0.23-0.64)] and other symptom(0.30-0.88)]. There was a trend toward improved and therapeutic interventions but this was not signThere was insufficient evidence on economic outcOverall, the review supported the positive effect o

care teams, though their effect size was small. 

Table 14i. Summary of reviews with entire focus on care coordination interventions: rheumatoid arthritis 

Reference Purpose Care coordination intervention and 

definition 

No. of 

articles

Results 

Badamgarav 2003s230

To determine the effect of disease management programs on functional status of

patients with rheumatoid arthritis 

Disease management: "a multidisciplinary 

intervention delivered by a team of health care professionals, providing a systematic approach to care, and including a patient education component. A multidisciplinary team was defined as 2 or more disciplines cooperatively involved in patient care"

11 Overall, disease management did not improve f

status in patients with rheumatoid arthritis [Eff95% CI: -0.01-+0.54)]. However, when interveexamined by duration and intensity, interventiolonger than 5 weeks showed significant improvpatient functional status [0.49 (0.12-0.86)] comthose lasting <= 5 weeks [0.13 (-0.25-0.52)]. Teffect on functional status based on the intensitintervention. 

89
Table 14j. Summary of reviews with entire focus on care coordination interventions: stroke 

Reference Purpose Care coordination intervention and 

definition 

No. of 

articles

Results 

Langhorne 2005219

To assess the effectiveness of early supported discharge (ESD) services 

ESD team coordination and delivery:multidisciplinary team coordinated discharge from hospital and postdischarge care and rehabilitation at home ESD team coordination: discharge and post discharge care planned and supervised by coordinated team; however, subsequent care provided by communitybased agencies 

7 2 

There was a significant reduction in death or deactivities of daily living among patients assigneteam [OR 0.79 (95% CI 0.64-0.97), p=0.02] coconventional services. There finding was also specifically in articles with a coordinated multiteam versus those without a team [0.70 (0.56-0vs. 1.23 (0.79-1.91), p=0.4, respectively]. Estimwere lower in the articles that described an ESD (median cost reduction 20%, range 4-30). 

90
Table 14k. Summary of reviews with entire focus on care coordination interventions: no specific clinical topic 

Reference Purpose Care coordination intervention and 

definition 

No. of 

articles 

Results 

LemieuxCharles 2006221

To provide an overview of health care team effectiveness, including conceptualization of terms and a model on how to approach evaluating team effectiveness 

Health care team: "a collection of individuals who are interdependent in their tasks, who share responsibility for outcomes, who see themselves and who are seen by others as an intact social entity embedded in one or more larger social systems (for example, business unit or corporation), and who manage their relationships across organizational boundaries"

33 Reported information on 12 studies evaluatin

effectiveness of team versus no team intervenstudies evaluating team redesign interventionmulti-site field studies. The authors present dof the included studies and provide a narrativThey suggest that the diversity and type of clexpertise involved in team decisionmaking mfor improved patient care and organizational effectiveness. Some factors likely to influencsatisfaction and perceived team effectiveness collaboration, conflict resolution, participatiocohesion. They also state, however, that the eevidence does not provide clear direction on hdesign or maintain high-functioning teams. 

Richards 2003222

To evaluate the effectiveness and costs of interventions that influence access to post-discharge services 

- Geriatric consultation teams (GCTs):Provision of needs assessment by a multidisciplinary team followed by recommendations for subsequent patient care - In-patient geriatric evaluation and management (GEM): Provision of needs assessment by a multidisciplinary team followed by implementation of treatment plans; concerned with patient management on the ward and recommendations for discharge planning.- Outpatient GEM: Provision of needs 

assessment by a multidisciplinary team followed by implementation of treatment plans; patient management concerned with postdischarge care. - Coordinator role: improve access to 

postdischarge services by combining the needs assessment and care plan with facilitating joint working with community agencies. 

3 7 5 5 

The review evaluated different methods of prneeds assessment and then linking the care pl

provision of services after discharge from the 

determine the effectiveness of each method. some evidence that interventions that emphasimplementation of care plans after discharge effective than those that focused solely on neassessment and discharge planning. 

91
Table 14k. Summary of reviews with entire focus on care coordination interventions: no specific clinical topic (co

Reference Purpose Care coordination intervention and 

definition 

No. of 

articles 

Results 

Payne 2002234

To assess the effectiveness of existing methods in the transfer of patient information 

between hospital and 

community 

Discharge coordination and key worker:

A key worker is one who can provide a point of contact for workers form hospital and community. Their presence is associated with improved discharge planning and coordination of services.

31 Current methods for transfer of patient inform

inadequate. Information transfer can be facilkey workers; however, there was insufficient to determine where the worker should be loca(hospital or community) or their professional background. Community-based practitioners lack of provision of appropriate and sufficieninformation. The barriers to effective informtransfer identified were: lack of time and coolack of discharge planning as a priority, fragmof information, and assumptions about the avof family support post-discharge. 

Briggs 2006236

To assess the effects of integration of primary care services on health care delivery and health status 

Integration of services: “a variety of managerial or operational changes to health systems to bring together inputs, delivery, management, and organisation of particular service functions. Integration aims to improve the service in relation to efficiency and quality"

5 The results did not indicate any clear pattern 

or harm from integration of primary care servBased on this review, no conclusions can be dabout the effects of integration on health servdelivery or health status in middle or low incocountries. There was neither a strong case fointegration of primary care services compared existing provision of health care. 

Johri 2003237 To analyze the 

impact of community-based long term care reforms and to common factors of an effective integrated care program for the elderly 

Integrated care program: comprehensive integration of acute and long-term care services 

7 Identified 7 successful integrated care progra

was no synthesis of outcomes; results are prenarrative fashion describing each of the 7 incprograms. The authors identified the followincommon elements in effective integrated care a single entry point system, case managemenassessment and multidisciplinary teams, and tfinancial incentives. 

92
Table 14k. Summary of reviews with entire focus on care coordination interventions: no specific clinical topic (co

Reference Purpose Care coordination intervention and 

definition 

No. of 

articles 

Results 

Zwarenstein 2001240

To assess the usefulness of interprofessional education interventions when compared to education in which the same professions learn separately from one another 

Interprofessional education: when members of more than one health and/or social care profession learn interactively together, for the explicit purpose of improving interprofessional collaboration and/or the health/well being of patients/clients; requires active learner participation and active exchange between learners from different professions

0 Since no articles met the inclusion criteria, th

insufficient rigorous evidence to evaluate the interprofessional education on professional prhealth outcomes. 

Grimshaw 2006244

To evaluate the effectiveness of interventions to improve referrals from primary care to secondary care 

No specific care coordination intervention studied 

17 The authors included all interventions (educa

organizational, financial) aimed specifically ainfluencing referral behavior. Improvements referral process may occur in the following inguidelines for referrals are distributed with stforms and involve consultants in education, osecond opinion or enhanced services are provbefore a referral. There was insufficient evidedetermine the effectiveness of financial intervreferrals. 

Gruen 2003245

To determine the effectiveness of specialist outreach clinics 

Specialist outreach clinics: planned/regular visits by a specialist practitioner from a usual location to 

primary care or rural setting; multifaceted 

outreach involved increased collaboration between primary care providers and specialists 

9 Specialist outreach can improve measures of 

(decreased cost, distance and travel time for pattendance to clinics, quality of care (guidelinconcordant care and adherence to treatment) outcomes. The included articles can be regaras collaborative care initiatives since they utioutreach as a way of integrating specialist and community services. 

93
Table 14k. Summary of reviews with entire focus on care coordination interventions: no specific clinical topic (co

Reference Purpose Care coordination intervention and 

definition 

No. of 

articles 

Results 

McCusker 2006246

To assess the effectiveness of comprehensive geriatric assessment interventions on reducing emergency department (ED) utilization 

Comprehensive geriatric assessment: No clear definition of the intervention provided; appears to include all interventions that include geriatric assessment 

26 The setting of the intervention and type of pa

targeted may have affected rates of ED utilizaInterventions in primary care and/or outpatienor home care settings appeared to reduce ED whereas hospital-based interventions appearelittle effect on ED utilization. Interventions wintegration with primary medical care and thotargeting high-risk patients also appear to redutilization. 

Mitchell 2002247

To assess the effectiveness of formal cooperation and liaison between general practitioners and specialists on patient outcomes 

Organised cooperation: a formal arrangement that links general practitioners with specialists in the care of patients 

7 Organised cooperation had mixed success for 

and functional health outcomes. There was a benefit of this intervention for some chronic mhealth conditions. The costs associated with establishing this formal relationship could noestablished. 

Zwarenstein 2000248

To evaluate the effect of interventions to improve nursedoctor collaboration 

Nurse-doctor collaboration: "collaboration was taken to mean sharing of information, coordination of work, and join decisionmaking on aspects of patient care"

2 There was limited evidence that structured nu

collaborations can improve length of stay witadversely affecting mortality. Neither of the included articles provided evidence on improcollaboration. 

94
95 

Summary of Reviews With Partial Focus on Care Coordination 

We included 32 reviews that had a partial focus on care coordination (Table 15). All of these 

reviews aimed at evaluating the effectiveness of a broad set of interventions across a variety of 

clinical conditions (e.g., nonpharmacological approaches to improving heart failure outcomes, 

strategies to improve medication use). As a result of these broad inclusion criteria, some of the 

articles included in these reviews involved interventions with a care coordination component. 

The care coordination strategies included in these reviews were highly heterogeneous and 

included the following: multidisciplinary teams, case management, disease management, 

integrated care, collaborative care and shared care, among others. The effect of these different 

strategies on outcomes was difficult to assess since most of the reviews failed to present analysis 

related to individual strategies but instead presented overall results for the broad set of included 

interventions.
Table 15. Summary of reviews with partial focus on care coordination interventions 

Reference Purpose Results 

Adli 2006273 To discuss algorithm-guided treatment for depression This review evaluated the effectiveness of algorithm-guide

studies on collaborative care that used algorithms to guide tshowed improvement in different outcomes measured (e.g.satisfaction with care and higher attrition rates). 

Aminzaadeh 2002275

To assess use of emergency department by older adults, risk factors associated with adverse health outcomes, and the effectiveness of intervention strategies 

 This review was primarily an epidemiologic review lookindepartments (ED) by older adults; it also included the risk fOne section of the review focused on interventions such as evaluation (5 articles) and coordinated discharge planning thowever, the data were inconclusive about the effectivenes

Andrews 2004267

To explore the roles of community health workers and their effectiveness in conducting research with ethnic minority women 

The review investigated using community health workers in minority women. In reviewing their roles, there were 4 arti

community health workers as case managers but this was inroles as educators or outreach workers. The authors reporte

health workers as case managers was more successful in rethem for outreach only" 

Ara 2004262 To evaluate the effectiveness of cardiovascular disease 

management programs in managed care populations 

The different interventions included in the different disease suggest some effectiveness in improving outcomes for cardspecific interventions that demonstrated effectiveness inclu

physician reminders and feedback, patient education and seSpecifically for CHF disease management programs, case mpatient monitoring were effective strategies. 

Badamgarav 2003263

To evaluate the effectiveness of disease management programs for depression 

This review searched for disease management programs for included several different interventions, of which multidisccomponent. The review, however, did not specifically proveffectiveness of multidisciplinary teams on outcomes but pmanagement programs as a whole. Overall, the pooled resusignificant outcomes for patients with depression who receiprograms. The results also indicated that these programs ca

Bijl 2004266 To evaluate the effectiveness of disease management 

programs in recognizing, diagnosing and treating major depression 

The review did not define disease management. Only one oour definition for care coordination. That study showed imintervention group for the outcomes reported: reductions of 3.45 (95% CI: 2.71-4.38)]; higher rates of treatment [2.98 (satisfaction with care; lower depression severity; less functgreater quality of life. 

96
Table 15. Summary of reviews with partial focus on care coordination interventions (continued) 

Reference Purpose Results 

Campbell 1999276

To review the effectiveness and problems of programs providing cancer care in rural and remote areas 

This review searched for all programs providing rural cancwith shared care of patients in rural areas between primary specialists in cancer care were included in the review. The make any recommendations about the provision of shared cremote and rural areas due to the limitations of article desigoutcomes reported. 

Crawford 2004252

To identify factors that promote or impede continuity of care for patients with severe mental illness 

Most of the evidence in this review came from qualitative factors that are important for continuity of care. Meta-anacoordination interventions such as case management, assertreatment and community mental health teams suggest that interventions can decrease the likelihood that patients will services. 

Dennis 2004251

To assess the effectiveness of interventions to prevent postpartum depression 

Only one article in the review reported on an element of camidwifery. There were no significant differences between midwifery versus standard care) with respect to depression insufficient evidence to recommend any of the intervention

Draper 2000255

To evaluate the outcomes of acute service delivery to older people with mental disorders 

This review provided on overview of the provision of old athe hospital and the community. One section reported resucontrolled trials that provided these services in a communiindicate that community old age psychiatry services are ef

Druss 2006256

To evaluate interventions to improve general medical care in patients with mental and addictive disorders 

The review provided an overview of all interventions desigcare. One study included a case manager and one included team with a facilitated referral to the community. The firsimprovement in the physical score of the SF-36 in the intersecond study reported no difference between groups. 

Duffy 2004250

To assess the evidence on nonpharmacological strategies for heart failure management 

This review assessed all nonpharmacological approaches tmanagement, including those that were not specifically relEight of the 15 included articles appeared to have some ele

coordination: multidisciplinary or case management. Overimprovement in quality of life and hospital admissions in tcoordination component. 

Eastwood 1996277

To assess the effectiveness of different methods of organization of asthma care 

The review evaluated different methods of organizing asthwas shared care between general practitioners and specialiincluded articles reported this intervention and suggested tshared care is comparable to conventional outpatient care. 

reported a lack of conclusive evidence favoring any particuasthma care. 

97
Table 15. Summary of reviews with partial focus on care coordination interventions (continued) 

Reference Purpose Results 

Gilbody 2003269

To evaluate the effectiveness of educational and organizational interventions to improve the management of depression 

Improved treatment adherence and/or improved depression with the more complex interventions: collaborative care, q(both organizational and educational interventions includepharmacist-provided information and education, guideline strategies that were accompanied by complex organization

Gonseth 2004260

To assess the effectiveness of disease management programs in reducing hospital re-admission among elderly patients with heart failure 

This review included all disease management programs; hoincluded articles reported some element of care coordinatiothese specific articles was not analyzed. Overall, meta-anashowed significant decrease in re-admission for heart failucause [RR 0.70, (95% CI: 0.62-0.79], all-cause readmissioreadmission or death [0.82 (0.72-0.94)] for participants in programs compared to usual care. 10 of these articles estimindicated that the implementation of a disease managemeneffective. Similar results were observed in the non-randomresults were observed among a heterogeneous group of pathealth care systems. 

Griffin 1998274

To assess the effectiveness of general practice versus hospital care for diabetes 

This review included “shared care” as an intervention stratnot defined. Two of the 5 included articles reported some coordination; however, the review did not analyze the effe

Overall, the review reported the effectiveness of computerprompting in improving outpatient care in the short term. 

Halcomb 2004268

To describe the role of practice nurses in heart failure management 

The authors identified two articles in which nurses played care as part of a multifaceted intervention. Care coordinat

and decreased hospitalization but did not affect health outc

Handford 2006257

To assess the effectiveness of the setting and organization of care on outcomes among patients living with HIV/AIDS 

The authors identified three studies evaluating case managevaluating either multidisciplinary or multi-faceted care. Cdefined differently for each study but always included a dimultidisciplinary care involved use of two or more provideclinician; multi-faceted care was the use of two or more trethan standard clinician care. All three case management st

improvements in selected outcomes (mortality, medication one study showed no difference in health care utilization umulti-faceted care studies showed mixed results for use of care utilization with some studies associated with increaseand others not. 

98
Table 15. Summary of reviews with partial focus on care coordination interventions (continued) 

Reference Purpose Results 

Harding 2005249

To assess the effectiveness of different models of providing palliative care on outcomes for patients with HIV/AIDS 

The review included all models of palliative care and did ncare coordination interventions. 15 of the included 34 arti

care coordination: multidisciplinary teams, case managemeHowever, because the analysis did not focus specifically oelements, it is not possible to draw any conclusions about tcoordination on patient outcomes. Overall, the evidence in

care at home and inpatient hospice significantly improved control, insight, spiritual well-being and anxiety. 

Harvey 2001278

To determine the effectiveness of existing interventions in improving health professionals’ management of obesity or patient outcomes 

The review searched for interventions aimed at professionareminders) as well as organizational interventions (e.g., muOnly one article that primarily addressed organizational inThis article aimed at improving collaboration between genhospital based obesity clinic through shared care and integarticle “indicated some positive effects in the short term...sustained over the long term” 

Hastings 2005279

To assess the effectiveness of interventions aimed at improving outcomes for elderly patients discharged from the emergency department (ED) 

The review included five observational, descriptive studies our definition for care coordination. Of these, three RCTs in functional status of intervention patients. All three studspecially trained nurse to perform geriatric assessment and review also reports that the targeting of high risk patients minterventions being more effective. 

Heideman 2005258

To assess effectiveness of interventions aimed at improving diagnosis and management of patients with anxiety disorders by general practitioners (GP) 

The review assessed the effectiveness of professional and ointerventions to improve care for patients with anxiety disostudies on collaborative care; one of which appeared to havanxiety outcomes. The intervention for this study included collaboratively with the GP to provide care. 

Hwang 2005259

"To summarize the existing evidence on interventions to improve health-related outcomes in homeless people" 

The review studied all interventions assessing health-relatehomeless people. It included 13 studies that had some commanagement and 6 studies that included the use of assertivteams. Overall, the review reported improved outcomes amproviding coordinated treatment and support. 

99
Table 15. Summary of reviews with partial focus on care coordination interventions (continued) 

Reference Purpose Results 

Ingersoll 2005271

To summarize the literature on the role of nurses as care coordinators or case managers for patients with diabetes 

Overall, there were 9 included studies; however, only 4 stucoordination with multiple providers. The remaining 5 stustudies with nurses providing care instead of physicians. Tstudies showed improvements in the respective outcomes sadmissions). One study intervention involved the referral care physicians to specialist care and showed significant delevels of 1.75 (95%CI: 1.4%-1.9%). 

Mitchell 2002253

To examine factors related to the delivery of palliative care by general practitioners 

The review provided an overview of general practitioner (Gpalliative care, including their self-assessment and trainingparagraph of the review that briefly addressed the importanpart of a palliative care team and suggested that when GPs together there is an improvement in "diagnostic accuracy, based treatments, identification of systematic problems in improved ability to facilitate deaths at home." 

Ofman 2004261

To assess the effects of disease management programs in patients with chronic disease 

58 of 102 (56% of the included articles) used multidisciplifor care; however, the specific effect of this strategy was nmanagement programs incorporating different strategies suprovider education, reminders and provider feedback, appediabetes, depression, hypertension, coronary artery diseaseLess benefit was shown for COPD and chronic pain. 

Pearson 2003264

To assess the effectiveness of interventions to improve medication use in managed care settings 

The review included articles with several interventions (indisease management, feedback) with most articles having mof the 48 included articles reported disease management as Disease management programs that focused primarily on dwere effective in changing processes of care and improvin

These results did not extend to those articles that examined months. 

Phillips 2004270

To evaluate the efficacy of comprehensive discharge planning and postdischarge support on outcomes among older patients with CHF 

12 of the 18 included articles reported some element of carincreased communication between providers, coordination management. Interventions involving home visits or extenassociated with significantly lower readmission rates. The interpreted with caution due to quantitative heterogeneity aintervention effects. 

100
Table 15. Summary of reviews with partial focus on care coordination interventions (continued) 

Reference Purpose Results 

Renders 2001254

To assess interventions targeting health care professionals or the health care system on the management of diabetes 

 This review examined a variety of interventions to improvthat target providers and the organization. Included in the articles that had some element of care coordination: multidmanagement. However, these components were combined such as education or follow-up, making it difficult to assescoordination component on outcomes. Most articles that incoordination components as part of the intervention showe

Sin 2003265 To evaluate the effects of anti-COPD therapies 

(pharmacological and nonpharmacological) on patient 

outcomes 

The review evaluated several commonly used anti-COPD tdisease management programs. 8 of the included articles amanagement and the interventions mostly focused on educand follow-up. The intent of the disease management progand coordinate care. Overall, there was insufficient evidenefficacy of disease management programs for patients with 

Vergouwen 2003272

To assess the effectiveness of interventions to improve adherence to antidepressant medications 

9 of the 11 collaborative care articles showed significantly depression outcomes in the intervention group vs. the contcollaborative care interventions included components (such education, treatment training, longer and more frequent visphysician and the health care system so it was not possible components accounted for improved adherence. 

Weingarten 2002148

To evaluate the effectiveness of disease management programs for chronic diseases 

The authors searched for articles evaluating disease managthen classified the different components of the intervention provider education, reminders). None of the intervention ccare coordination focus. Overall, the review reported that showed improvements in disease control and provider adh

101
102 

Narrative Synthesis of Recent Systematic Reviews by 

Coordination Component 

Decisionmakers are interested in a more granular analysis of the effect of components of care 

coordination interventions. As described in Chapter 3, we developed a components list of 

essential tasks of care for a patient, associated care coordination activities, and features to 

support the activities. We reviewed 15 recent systematic reviews to assess if the reviews 

provided any information on specific components of the care coordination intervention. We 

mapped the information provided to the components deemed important when evaluating care 

coordination interventions (Table 16). Of the 15 reviews, 13 provided some detail on either the 

care coordination intervention or details on the individual studies included in the review; six 

reviews performed some analysis by selected components; four provided quantitative analysis. 

When we apply this type of components list, we see that some interventions are aimed at (or 

incorporate delivery of) a subset of tasks and may have a few specific features to accomplish 

those tasks. Our ability to determine the presence or absence of each component reflects some 

assumptions, given the modest level of detail typically supplied for the intervention reviewed. 

Fairly uniformly, the systematic reviews provide little to no meaningful analysis at the 

component level. However, the application of a component list allows us to observe potentially 

important nuances. For example, one of the systematic reviews compared multidisciplinary 

teams to nurse-led teams, and found the former to appear more effective. We note that the tasks 

specified in the review were fairly limited – care planning and communication. The authors did 

not describe details about assessment, execution of care plan, monitoring and evaluation tasks, 

even though these activities may have been present. They noted that the nurse-led interventions 

tended to be more focused on patient education and follow-up visits or calls. Therefore the 

differences between the two types of interventions are more complex than simply “nurse-led” or 

“multidisciplinary”, and application of the list reminds us to examine each component that could 

affect the outcomes. 

Summary. The current evidence base does not support a granular, component-level analysis 

from systematic reviews. Our impression from the literature reviews presenting detailed 

intervention descriptions of the primary studies is that they also will fall short of being able to 

address the question of what components of interventions are most critical for a given 

coordination challenge. Therefore, we anticipate that new primary research with appropriate 

(and likely novel) designs is necessary as a basis for later syntheses to provide definitive answers 

on what to do for each coordination challenge.
Table 16. Components described or evaluated by the systematic reviews 

Review Intervention Care Tasks/

Coordination 

Activities* 

Features* Quantitative 

Patient 

Outcomes 

Evaluation by 

Component(s)? 

Comm

Craven209 Collaborative 

care 

I, C TOOL, 

REDESIGN 

NO NO Provided detailed descripti

study. 

Gunn210 System level 

interventions 

I, C, M TOOL YES (+) NO 

Holland216 Multidisciplinary 

interventions 

A, I IT, TOOL YES (+) YES Analyzed subgroups: One 

[TOOL] mattered. Patient tpatients [ASSESSMENT] 

LemieuxCharles221 Team I, C, M TOOL NO NO Provided detailed descripti

study. 

Gohler224 Disease 

management 

D, I, M TOOL, 

TECHNIQUE 

NO PARTIALLY Analyzed intervention char

composition, intervention mduration of followup) in orheterogeneity across studie

Roccoforte225 Comprehensive 

disease 

management 

D, I TOOL YES (+) YES Sensitivity analysis found t

programs better than nurse[PARTICIPANT ROLE] 

Whellan226 Disease 

management 

I - NO NO Authors reported lack of in

components in the primary 

Yu227 Disease 

management 

D, I, M IT, TOOL YES (+) YES Categorized studies into ef

based on key characteristicEuropean Society of Cardiowere more likely to involve cardiologist; having the PCROLE] as a member of the to result in more promising 

Knight228 Disease 

management 

M - YES (+) YES A program involving pharm

and adjusting medications programs involving combininterventions were associatchanges in GHb. No furthe

Krause229 Disease 

management 

C - NO NO No description of intervent

103
Table 16. Components described or evaluated by the systematic reviews (continued) 

Review Intervention Care Tasks/

Coordination 

Activities* 

Features* Quantitative 

Patient 

Outcomes 

Evaluation by 

Component(s)? 

Comm

Briggs236 Integration of 

primary care 

services 

A - NO NO 

Dohan192 Navigation 

programs 

I, C NO NO 

McCusker246

Individual studies 

Comprehensive 

geriatric 

assessment 

A, D, I, C 

TOOL, 

TECHNIQUE, 

REDESIGN 

NO PARTIALLY Narrative synthesis examin

characteristics to see which improvements in ED utilizaRCTs evaluated multidiscipliaison intervention, a case with primary care; neither utilization”. “Other characthat may reduce ED utilizaintegration with primary mof the intervention to highewas...insufficient number asses the effects of these fa

* A component is listed if it is obvious from the description that it was part of the intervention. Other components may well be present, but not describ

with confidence. Care tasks/Coordination Activities: A=Assess Patient, I=Identify Participants and Role, D=Develop care plan, C=Communication, E=Execute care pla

Features: IT=Information technology, TOOL, TECHNIQUE to mitigate interface issues, REDESIGN of system to support care coordination 

104
105 

4D. Discussion 

Our review of systematic reviews evaluating care coordination interventions suggests that 

many care coordination strategies have demonstrated effectiveness for selected outcomes within 

a particular clinical area, though the cumulative evidence across systematic reviews is less clear. 

Our review had the following key findings: First, care coordination interventions that have been 

evaluated are highly heterogeneous and tend to focus on several discrete clinical areas. Second, 

coordination strategies are defined differently across reviews, with no single definition for very 

similar strategies. Third, the evidence suggests that care coordination interventions can improve 

outcomes in different diseases (mortality and hospital re-admission in patients with heart failure, 

glycemic control in patients with diabetes, depression severity and treatment adherence in 

patients with mental illness, death or dependency in patients with stroke); however, there is a 

lack of evidence about the superiority of one particular strategy over another. Finally, there is 

insufficient evidence regarding the costs and cost-effectiveness of care coordination 

interventions. In summary, the diversity of the care coordination interventions evaluated, the 

heterogeneity of the definitions of the interventions, and the diversity across clinical conditions 

and populations limit our ability to synthesize the reviews; however, the evidence does suggest 

that multidisciplinary teams, case management and disease management programs are associated 

with improved outcomes. 

4E. Limitations 

This review has several limitations. First, we attempted to find all reviews that addressed 

some element of care coordination; however, we may have missed certain reviews that were not 

clearly focused on care coordination but which may have included articles that addressed care 

coordination as a result of a part of a broader search. Second, the included reviews were highly 

heterogeneous with respect to the care coordination interventions included. Many reviews failed 

to provide a clear definition of the care coordination intervention being studied. Additionally, a 

single care coordination term (e.g., disease management, assertive community treatment) was 

defined in different ways across different reviews, making it impossible to draw firm conclusions 

across reviews. Third, care coordination interventions were studied across several different 

clinical topics (heart failure, mental illness, diabetes, asthma, stroke, rheumatoid arthritis, pain 

management, palliative care) and it was unclear if interventions that were effective in one area 

would be effective in another area. Fourth, because reviews did not always have a clear focus on 

the analysis of the care coordination process or structure, it was difficult to interpret the 

effectiveness of care coordination in improving outcomes. Finally, we were limited by the 

methodology used for this chapter; our strategy of reviewing systematic reviews left us unable to 

review the primary findings of the articles included in the reviews. Therefore, it is possible that 

key pieces of information were missed since they were not provided in our included reviews. 

 
106 

4F. Summary Answers to Key Questions 

Research Question 5: Which Care Coordination Interventions Have 

Been Evaluated by Systematic Reviewers and How Were 

They Defined? 

Among our included reviews, we identified various care coordination interventions that have 

been evaluated. The terms used to define the care coordination strategies were highly 

heterogeneous. The 43 individual reviews that focused entirely on care coordination referred to 

20 different care coordination interventions. The most common strategy evaluated the use of 

multidisciplinary teams involving two or more providers from different specialties providing 

care to a group of patients (15 reviews); the terms applied to this strategy included 

multidisciplinary teams, team coordination, assertive community treatment, collaborative care, 

integrated programs, and shared care. The next most common strategy evaluated was disease 

management (ten reviews). It was defined variably or not at all in the included reviews and there 

did not appear to be a consensus about the components that should be included in a disease 

management program; however, the intent of all the disease management programs reviewed 

was to improve the coordination of patient care, provide support to patients, and improve patient 

outcomes. Finally, nine reviews assessed the role of case management (also referred to as care 

management) which typically involves the assignment of a single person (case manager or “key 

worker”, so named in one study) who coordinates all aspects of a patient’s care (e.g., providing 

information to multiple providers, seeing that the patient receives services in a timely manner 

etc.). The qualifications and exact duties of case managers were poorly described in most 

reviews. Other strategies evaluated were integration of care (three reviews), and 

interprofessional education, defined as the provision of training and education to professionals 

from different health and social areas, who learn together interactively (three reviews). 

Research Question 6: What is the Evidence Regarding the Health 

Benefits of These Care Coordination Interventions as Summarized in 

the Systematic Review(s)? In Particular, is the Effectiveness of Care 

Coordination Interventions Related to the Setting in Which Care is 

Being Coordinated, the Component of Care Being Coordinated, or the 

Type of Disease or Patients for Whom Care is Being Coordinated? 

Numerous care coordination interventions were evaluated across several diseases among the 

included systematic reviews, with different outcomes being reported within each review. Only 

three care coordination strategies-multidisciplinary teams, case management, and disease 

management-were evaluated across different clinical topics (e.g., heart failure, diabetes). 

Overall, the reviews reported a positive effect of these strategies on the outcomes studied 

(improved mortality and hospital readmission rates in patients with heart failure, improved 

glycemic control in patients with diabetes, improved service continuity in patients with mental 

illness). The remaining reviews evaluated other care coordination strategies (comprehensive, 

multidisciplinary program, integrated care, shared care, organized clinic) within a single clinical 
107 

topic thereby limiting our ability to synthesize the evidence on the effectiveness of those care 

coordination strategies across clinical topics. 

Interventions were conducted across different settings (home, community, outpatient clinic), 

with half of the reviews conducting interventions across multiple settings. One review216

reported that interventions with a home-based component or telephone follow-up were more 

effective than those based in the hospital or clinic; however, due to a lack of analysis of the 

effectiveness of the care coordination intervention by setting, there is insufficient evidence to 

allow for any definitive conclusions regarding the effect of setting on the effectiveness of care 

coordination interventions. Furthermore, there was also insufficient evidence to determine the 

effectiveness of any particular care coordination intervention in improving patient outcomes 

across care boundaries. 

In our included systematic reviews, care coordination interventions were frequently 

evaluated among patients with mental health problems. Several different strategies were studied 

among this population. Most of the reviews reported improved outcomes for each strategy; 

however, there was insufficient evidence that one particular strategy was more effective than 

others in improving outcomes. Care coordination interventions among patients with heart failure 

were also studied extensively, with multidisciplinary teams and disease management being the 

main interventions. While the reviews reported improved outcomes (mortality, hospital readmission) associated with both these interventions, there was considerable overlap of the 

included studies across the reviews. The remaining reviews evaluated care coordination 

interventions among a diverse group of clinical conditions (diabetes, asthma, heart condition, 

stroke, rheumatoid arthritis) thereby limiting our ability to synthesize the findings for a given 

intervention. 

Most of the included systematic reviews evaluated care coordination interventions in adults 

in the general population. Eight of the reviews evaluated interventions among the elderly, a 

vulnerable group more likely to have poorly coordinated care. The findings from these reviews 

suggest that care coordination strategies may improve outcomes among elderly patients 

(specifically by decreasing hospital admissions); however, the heterogeneity of the included 

strategies do not permit any further synthesis that would allow us to assess the effectiveness of 

one particular strategy over another. 

The intervention descriptions provided by the most recent systematic reviews were generally 

not adequate enough for a complete categorization of the intervention components. The current 

evidence does not support a granular, component-level analysis from systematic reviews. 

The overall quality of the included systematic reviews was very good, with most reviews 

providing detailed search terms, inclusion/exclusion criteria and appropriate synthesis of their 

included articles. 

Research Question 7: Have the Costs of Care Coordination 

Interventions Been Evaluated in any of These Systematic Reviews, 

and if so What is Known? 

Costs were evaluated in approximately half of the included reviews that focused solely on 

care coordination; however, only one of the reviews reported findings on the costeffectiveness/cost-benefit of the care coordination intervention. The evidence from this review 

suggests that comprehensive disease management programs are cost-effective for improving 

outcomes in patients with depression. One other review reported a summary effect size of the 
108 

economic effectiveness of disease management programs indicating that disease management 

programs were economically effective. The remaining reviews provided some cost estimates of 

the interventions evaluated; however, the evidence was insufficient to allow for any definitive 

conclusions regarding the costs and benefits of the care coordination interventions evaluated.
109 

Chapter 5. Conceptual Frameworks and Their 

Application to Evaluating Care Coordination 

Interventions 

5A. Background 

As noted in the previous chapters, a diverse set of large scale care coordination projects are 

being planned or are underway with the support of the Center for Medicare & Medicaid 

Services,32, 280, 281 the Department of Veterans Affairs,147 professional organizations, and 

foundations.188 The vast majority of healthcare systems and managed care organizations 

reported have disease management programs,64 though these programs vary significantly in their 

design.187, 282 In addition, the research literature includes numerous studies reporting evaluations 

of care coordination interventions. Efforts to identify optimal strategies for coordinating care 

have been impeded in part by the lack of conceptual frameworks to guide the evaluation of care 

coordination interventions, as well as by uncertainty regarding how best to measure coordination 

itself.50, 93, 119, 283 To evaluate the effectiveness of interventions for improving care coordination 

and the validity of instruments used to measure care coordination, the concepts related to care 

coordination need clarification. 

This chapter discusses some of the literature on conceptual frameworks and related metrics 

either directly or potentially applicable to care coordination. The purpose of this discussion is 

two-fold: to provide brief descriptions of selected potentially useful frameworks and to 

demonstrate how these frameworks might be used to guide development, implementation, and 

evaluation of care coordination interventions. Thus, the purpose of this chapter is to show that 

theoretical thinking from different fields has the potential to enrich the study of care coordination 

interventions. The goal is not to develop one integrated theory, as that is a major step beyond the 

scope of the current work. However, the frameworks presented in this chapter show that there 

are multiple alternatives to hypothesizing how an intervention might cause (or not cause) a 

desired effect. 

5B. Methodological Approach 

Similar to the methods described in detail in Chapter 3, we used iterative searches to identify 

literature describing conceptual frameworks and associated empirical evidence related to care 

coordination. We reviewed theoretical work developed in the behavioral, organizational, and 

health services research fields, and adapted selected frameworks to care coordination. While 

there are many potential frameworks from these and other fields, we chose well-established 

frameworks that had previously been used in or adapted to the health care setting, offered 

relevant concepts based on our discussions with experts in the field, and/or provided 

complementary ideas for understanding care coordination. Finally, we also searched for 

measures related to care coordination and summarized key information about some example 

measures and describe their relationship to the frameworks. We focused on providing 

information of relevance to potential decisionmakers and others involved in care coordination. 
110 

Focusing the Conceptual Frameworks on Key Decisionmakers 

After our review of the types of care coordination programs underway (Chapter 2) and care 

coordination interventions evaluated in systematic reviews (Chapter 4), we decided to focus our 

conceptual framework on two levels of decisionmaking related to care coordination: systemlevel policymakers and service-level decisionmakers. By system-level policymakers (e.g., State 

Medicaid directors, Medicare officials, health plan managers), we mean individuals who have 

responsibility for paying for health care services for large numbers of individuals (i.e., health 

plan enrollees, Medicare beneficiaries) and make decisions about how to coordinate care at a 

system level in ways that minimize their financial risks and maximize the health care outcomes 

of their population of patients. By service-level decisionmakers (e.g., a primary care doctor, 

managers of a multi-specialty clinic), we mean individuals who are involved in providing health 

care services to individual patients or a panel of patients, and therefore tackle care coordination 

at the service delivery level. Depending upon the particular local environment, they make 

decisions related to care coordination to maximize health care outcomes and profit. To varying 

degrees, both the systems and delivery decisionmakers have shared responsibility for making 

care safe, effective, patient centered, timely, efficient, and equitable (the six IOM goals for 

quality healthcare). As we discuss specific conceptual frameworks, we will explore how each 

framework could help inform decisions related to care coordination for both of these types of 

decisionmakers. 

The patient, of course, offers another key perspective to consider as we explore and apply 

specific frameworks. A focus group of hospitalized patients found that patients perceived that 

clear communication reflected good care coordination, and had varying opinions about who has 

responsibility for coordination (e.g., doctor, nursing supervisor, nurse, patient, etc.).284 With 

mounting interest in consumer-driven health plans and patient- (and family-) centered care, it is 

likely that the patient will have an increasingly active role in health care decisionmaking.285, 286 

The patient is often the decisionmaker who experiences issues of coordination failures, so all 

frameworks apply to this key participant in care. 

5C. Results 

Malone and Crowston have argued for the utility of interdisciplinary study of coordination 

that draws from the fields of computer science, organizational theory, economics, psychology, 

management science, linguistics and biology, and have even provided a first synthesis of some 

common themes in relationship to information technologies.117 While we see the value of 

integrating across fields to develop a common conceptual framework of care coordination, we 

recognize that such a goal goes beyond the scope of this report. As a result, we have limited our 

scope to four frameworks from the fields of behavioral science, organizational design, 

management sciences, and health care that seem particularly relevant to the questions posed by 

care coordination decisionmakers (Chapter 2). We required that frameworks selected from these 

different fields include potential cause and effect relationships among the concepts included in 

the frameworks.*

 In the following sections, we describe each framework and the concepts that 

 

*

 We have focused our review on frameworks that might help intervention designers analyze their situation and 

tailor solutions based on an understanding of the cause and effect relationship of various concepts. As a result, we 

have not included many current models that bundle interventions together into holistic approaches to improve 
111 

are likely to be particularly useful to decisionmakers. We then present some examples of metrics 

related to care coordination, and how they relate to the frameworks and evaluations of care 

coordination. Finally, we apply the concepts from these frameworks and metrics to our findings 

from the previous sections of this report to show how such an approach might be useful to those 

designing and evaluating care coordination interventions and programs. The intent of the rest of 

this chapter is to understand what factors might enable well-coordinated care in a variety of 

scenarios. 

Model 1: The Andersen Behavior Framework 

Since health care delivery relies greatly on individuals, we searched the sociology and 

psychology literatures for relevant frameworks and found a useful one originally developed by 

medical sociologist Ronald Andersen and adapted over the past 35 years by many others.287 The 

original framework from the 1960’s lays out the some of the most salient concepts for care 

coordination. Originally intended to predict and explain use of health care services by 

individuals, the Andersen behavior model has recently been applied to model clinician response 

to quality-based payment incentives.288 We adapt the purpose here to focus on the coordination 

behaviors of health care delivery participants (including patients and clinicians, as defined in 

Chapter 3). We also refer the interested reader to the first report of this Closing the Quality Gap 

series for a descriptions of behavioral change theories.289 

Figure 3 shows the initial framework with our substitution of the word “coordination” for 

“use.”** Deceptively simple, the framework suggests that coordination of health services relates 

to three concepts: the participants’ predisposition to coordinate care, the resources that enable or 

impede coordination, and the participants’ need for coordination. 

Figure 3. Andersen Behavior Framework 

 coordination. For example, the Wagner Chronic Care model has been applied widely as a package of approaches to 

activating patients and developing effective health care teams with adequate support from the community and the 

health care system. In the section on the third framework from organizational sciences, we describe how the Wagner 

model is consistent with organizational design concepts. 

** In each of the figures describing the conceptual frameworks relevant to care coordination, we adopt the following 

graphical convention: We use a box with square corners to depict the concepts related to the baseline assessment of 

the care coordination setting, patient population, and other existing factors in the health care environment. We use a 

box with rounded corners to depict the coordinating mechanisms, and we use a shaded diamond to depict the 

outcomes of care coordination. 

Predisposing 

Characteristics

motivate

Enabling

Resources

support or 

impede

Need for

Coordination

stimulus

Coordination 

of Health 

Services

behavior
112 

First, some participants might be more or less predisposed to coordinate care based on their 

own attitudes toward or knowledge about their role in coordinating care. The idea behind 

predisposing characteristics is that they are not easily altered. Another predisposing 

characteristic in the context of care coordination might be the structure of medical professions, 

which set certain expectations about who has responsibility for specific care activities. Shifting 

major responsibility to the patient for example, for coordination of their own care, would go 

against the norms of some care professionals. Numerous other predisposing characteristics have 

been shown or hypothesized to relate to improvements in care, potentially through effects on 

care coordination behaviors: incentives, climate and culture, staff expertise, 

leadership/commitment to quality improvement,109, 290-293 pre-existing team/group or interclinician factors (e.g., team structure, collaborative practice),136, 164, 294-298 and individual clinician 

characteristics (e.g., knowledge, attitudes, and skills).96, 99, 140, 299-301 Since predisposing 

characteristics are difficult to change, more resources or creativity would likely be necessary if a 

clinician, patient or systems-level decisionmaker wanted to reduce a barrier related to these 

characteristics. 

Second, enabling resources reflect the availability and access to the requisite information 

systems, organizational structures, or productive relationships with others providing care to the 

same patient. Enabling resources affect the ability of a participant to respond to the need for 

coordination. A key distinguishing feature of enabling resources (compared to predisposing 

characteristics) is that they may be changed by systems- or service-level decisionmakers. 

Interventions to improve care coordination typically involve changes to enabling resources (e.g., 

introduction of a protocol for handoffs or designating a nurse as a patient navigator at the service 

delivery level; and implementation of contracts with disease management organizations or 

changing payment policies at the systems level). More details about potential enabling resources 

will be covered in a subsequent section on organizational theory and design. 

Classification of predisposing characteristics and enabling resources is a function of point of 

view. For example, a doctor working within a particular healthcare system would see a lack of 

an information system as a predisposing characteristic since he or she alone could not change the 

situation. However, the leader of the same system may make a choice about whether to invest in 

information systems, making the same factor an enabling resource. Thus, the service-level 

decisionmaker and the systems-level decisionmaker will have different views of predisposing 

characteristics versus enabling resources. 

Third is the notion of the need for coordination. In Andersen’s original model the need to 

utilize health care is based on the patient’s health and functional state, and his/her perception of 

need for health care. Illness is therefore typically the trigger for using health care services. In 

the adapted care coordination framework, we assume that one or more of the participants must 

perceive a need for coordinating care in order to trigger actual coordination behaviors by the 

participants (e.g., exchanging information between two clinicians at the delivery level; setting up 

a registry to flag more complicated patients for intensive case management at the delivery or 

systems level). The need for coordination is likely a function of the patient when we consider 

the health care delivery level, and of the patient population when thinking about the system level 

(e.g., Medicare). Patients whose health requires the participation of multiple participants (e.g., 

several doctors for multiple chronic conditions, a rehabilitation therapist for post-stroke care, a 

social worker for connecting the patient to community resources, a pharmacist to help sort out 

Medicare Part D benefits, etc.) need more coordination of their care. 
113 

While this model is described using a general concept of coordination, it applies to any 

behavior related to coordination. In viewing coordination through a behavioral model, designers 

and evaluators of care coordination interventions might be motivated to ask, for example, “What 

behaviors need to change to improve coordination between medical and non-medical services? 

The focus is then on a specific element of coordination – coordination across services—

presumably because patient complaints perhaps stimulated a desire to change the behavior 

related to this element of coordination. The situational analysis then would review predisposing 

and enabling factors that create barriers and opportunities for achieving the specific behavior 

change – coordinating more effectively among participants from medical and non-medical 

services – in order to design and test an appropriate intervention. Thus, application of this model 

involves potentially focusing on discrete elements of care coordination (e.g., smooth exchange of 

information, efficient planning and delivery of disparate services, education of patients about the 

care plan, adherence to treatment) and mapping out what behaviors need to change (e.g., the 

physician needs to describe to patient and support staff the non-medical service needs 

envisioned, and the support staff person needs to take responsibility for effectively linking the 

patient to the appropriate non-medical resources). The choices of appropriate interventions to 

improve coordination are likely to be more self-evident by breaking the analysis up into discrete 

coordination problems. 

Model 2: Donabedian’s Quality Framework 

Well known to those involved in health care quality research, Avedis Donabedian described a 

framework for assessing the quality of care that is flexible enough to apply to many situations.302 

Figure 4 illustrates the intuitive relationship between three related concepts. First, structures of 

health care are defined as the physical and organizational aspects of care settings (e.g., facilities, 

equipment, personnel, operational and financial processes supporting medical care, etc). Second, 

the processes of patient care sit in the middle of the diagram because they rely on the structures 

to provide resources and mechanisms for participants to carry out patient care activities. In 

addition, processes are performed in order to improve patient health in terms of promoting 

recovery, functional restoration, survival and even patient satisfaction. This latter concept is 

well-known as the outcomes of medical care. 

Figure 4. Donabedian’s Quality Framework 

Structures of

Care

setting

Processes of

Care

care delivery and

care coordination

Health 

Outcomes
114 

In the context of care coordination, we note that health outcomes result from the medical care 

delivered to the patient and the patient’s underlying characteristics. In focusing on the linkage 

between what is under the control of the medical profession and effects patient outcomes, 

Donabedian’s framework purposely does not account for patient, economic or social factors 

outside of the care delivery system. In his seminal 1966 paper, republished recently, Donabedian 

states: “This is justified by the assumption that one is interested...in whether what is now known 

to be “good” medical care has been applied. Judgments are based on considerations such as the 

appropriateness, completeness and redundancy of information obtained through clinical history, 

physical examination and diagnostic tests; justification of diagnosis and therapy; technical 

competence in the performance of diagnostic and therapeutic procedures, including surgery; 

evidence of preventive management in health and illness; coordination and continuity of care; 

acceptability of care to the recipient and so on.”303 Thus, the framework has coordination of care 

listed in the process box, meaning that care coordination is expected to be influenced by the 

setting and other structure variables and to exercise causal effects on patient outcomes. Another 

take-home point from this framework is that the positioning of care coordination implies that it is 

one of many important care processes, and therefore does not act in a vacuum even at the level of 

service delivery. In focusing on care coordination, it is easy to lose sight of this important, 

though relatively obvious point. Coordinating care better is only beneficial if other aspects of 

care delivery are optimized as well. 

For a given care delivery setting—for example a small office-based physician practice—the 

coordination process of information exchange (e.g., test results conveyed from laboratory to 

physician) depends on the structures in place (e.g., information system linked with lab, fax 

machine). To coordinate care better, the physician may consider a structural change – 

purchasing an information technology solution to receive and flag results that need action, or 

adding staff time to perform the same function. The process could also be modified through a 

standard protocol to guide how the information flows, and to designate who has responsibility 

for each step under specific circumstances. Outcomes relevant to the information exchange 

process could include patient satisfaction with communication, timeliness of care, and clinical 

outcomes dependent on the information conveyed (e.g., better control of clotting times based on 

changing anticoagulant drug dosing). At the systems level—for example, an integrated health 

care system, the structural change might be to create an anticoagulation clinic to co-locate 

testing, results reporting, and clinician visits. The coordinating process would be teamwork, and 

the outcomes would be the same as in the first case. 

Model 3: The Organizational Design Framework 

The organizational theory literature offers numerous relevant concepts for thinking about 

care coordination, and for simplifying the complexities of the effects of the actions of multiple 

participants on multiple coordination parameters. Many studies outside of and within health care 

have focused on the effects of factors associated with organizational decisions on coordination 

and organizational effectiveness. However, there is not a single established framework that 

seems fully applicable to the questions posed by care coordination decisionmakers. Instead, 

several key concepts offer important lessons to consider in designing and evaluating new 

approaches to care coordination. To present these concepts as accessibly as possible, we anchor 

our discussion using a framework of formal coordinating mechanisms from organizational 

design research. For those decisionmakers who have a span of control within one organization 
115 

that provides integrated care to patients, the organizational design framework could readily 

apply, and offer a way to generate potential solutions appropriate to the particular demands of a 

care coordination problem. In contrast, for systems-level decisionmakers whose policies affect 

multiple organizations, the framework we present is largely illustrative of the types of failures 

that could occur among or within organizations participating in patient care. The organizational 

theory literature describes the relationships among organizations that together produce a good or 

a service; however, a detailed review of this information is outside the scope of this report. We 

direct the interested reader to Gittell and Weiss105 for a cogent detailed description of a “multilevel framework for coordination” applied to health care. 

The general organizational design framework shown in Figure 5 characterizes organizations 

as information-processing systems, where the flow of information among participants is a 

function of the demands of the situation and the capabilities of the organization to move 

information to where it is needed. The framework presents three concepts that underpin choices 

about organizational design: information requirements, information-processing capacity, and the 

match or fit between these.304

First, different situations produce variable information requirements, as shown on the left 

side of Figure 5. Studies within and outside of healthcare suggest that several basic 

characteristics of the organization’s task or in the case of health care, the specific patient care 

activities, have important implications for designing coordination mechanisms to facilitate 

information flow effectively: interdependence, uncertainty and complexity of patient care 

activities.130, 164, 304-307 

• In order to successfully perform their respective care activities, participants often rely on one 

another for information or other resources. As the level of interdependence among 

participants increases, so do the demands for information among participants.130, 138 A higher 

level of information flow is required in situations of reciprocal interdependence, such as for 

complex patients and referrals between physicians. Information flow between physicians is 

bi-directional, thereby increasing the demands for timely exchange of information. 

• Uncertainty is ubiquitous in health care and results from a lack of information about what 

will happen in the future. The course of disease or treatment for a particular patient may be 

unpredictable. Participants working in situations of greater unpredictability tend to need to 

exchange information quickly and make numerous adjustments to meet changing patient care 

needs. 

• Complexity relates to the amount of information required to manage a patient or group of 

patients. For patients with multiple chronic conditions, there are increasing needs to collect 

and respond to more symptom, diagnostic and monitoring information. Complexity also 

increases with the number of participants from different organizations, professions, or 

geographical location that must be engaged in care activities.308
116 

Figure 5. Organizational Design Framework 

The second key concept shown in the middle of Figure 5 is that the capacity of the 

organization to provide information must match, or fit the demands for information by the 

participants carrying out the patient care activities. In other words, the designs of structures for 

information-processing affect the ability of the participants to get the information they need to 

carry out their respective patient care activities. A care coordination intervention, therefore, 

needs to be appropriate for the coordination problem. While there may be multiple approaches 

to designing a good fit between information requirements and organizational capacity, some 

approaches may be more cost-effective than others.304 Designing in more expensive forms of 

coordination may be necessary for the most interdependent, complex and uncertain situations as 

shown in Figure 6. But simpler interventions such as standardization (e.g., implementation of 

care pathways) may be effective enough for lower interdependence situations. 

Information 

processing 

capacity

Information 

processing 

requirements Good

Fit

Interdependence

Uncertainty

Complexity

Grouping

Structural Linking

Operational 

Processes

Coordinating 

Mechanisms Settings and Patients

Effective and efficient

organization providing 

coordinated care
117 

Figure 6. Schematic of relationships between situational characteristics and appropriate care 

coordination approaches 

Thus, just as the characteristics that drive the amount, timing and types of information flow 

required for care activities vary by patient need and other situation characteristics, organizations 

can be designed with differing types of information-processing capacity, the third main concept 

shown on the right side of Figure 5. The movement of information is a function of decisions 

about the structure of the organization, with three main areas that designers can change: grouping 

of participants, structural linking between participants and operational processes, as shown in the 

right rounded rectangle in Figure 5.304 It is worth noting that these areas could easily be 

subsumed within the Donabedian framework’s structure concept, but we have additional insight 

from organizational design that these particular areas relate directly to facilitating information 

exchanges, and therefore act as coordinating mechanisms, which in turn can be described by 

three areas of leverage. 

• Grouping involves putting participants together (or separating them into units). A 

multidisciplinary clinic aggregates various specialties into one setting making it possible for 

information and patients to move more easily between physicians. For example, a patient 

diagnosed with prostate cancer might be rapidly seen by his primary care physician, a 

urologist, and a radiation oncologist to determine the best course of treatment. If physicians 

are practicing more independently, such coordination of visits might take longer and 

information flow might be less reliable. For example, consider an elderly patient diagnosed 

with breast cancer in a small community requiring oncology care in a distant tertiary care 
118 

hospital. She may have to coordinate the transfer of medical records and other critical health 

information across geographic and institutional barriers to facilitate her care. The 

information requirements in both situations are similar, but the organization of participants 

either facilitates or impedes information flow. 

• Various formal mechanisms can be used to coordinate care across organizational boundaries, 

and are referred to as structural linking. Examples of these mechanisms that operate mostly 

at the service delivery level include designating participants as liaisons (e.g., primary care 

physicians often fulfill this role based on their training and professional sense of 

responsibility to the patient), creating a coordinating committee comprised of participants 

from different groups (e.g., a guidelines committee), and hiring someone into an integrator 

role (e.g., a case manager to facilitate efficient care for particularly complex patients). At the 

system level, other higher powered mechanisms might be applicable, such as addition of an 

organization playing an integrator role (e.g., disease management vendors), or development 

of management structures where participants are accountable to more than one group (e.g., 

employer purchasing groups exercise some authority over health care providers through 

voluntary quality reporting requirements, while these same providers are accountable directly 

to their patients). 

• Operational processes include standardization, adjustment, monitoring and organizational 

support, which are defined in Table 17. For example, standardization uses formalized 

mechanisms that pre-specify the roles, responsibilities and activities of individuals, or specify 

intermediate outputs, or skill sets needed for specific activities. Practice guidelines, care 

maps and protocols are examples of standardization (Table 17). 

Table 17. Operational processes 

Operational 

Process 

Definition Healthcare Examples 

Standardization Formalized mechanisms that pre-specify the 

roles, responsibilities, and activities; the 

specifications of intermediate outputs; and/or 

the skill sets needed to perform specific 

activities.309, 310

- Practice guidelines 

- Care maps 

- Protocols 

- Clinical pathways 

- Checklists 

- CME (continuing medical education) that 

aims to standardize skills or knowledge 

Adjustment Mechanisms that facilitate ongoing assessment 

and adjustment of roles, responsibilities, and 

decisions among multiple participants, either 

between individual participants or among a 

designated group of participants.91, 130, 141, 305, 309, 

310

- Individual performance feedback 

- Team meetings 

- Consultations 

- Multidisciplinary patient rounds 

Monitoring Mechanisms to facilitate timely assembly of 

information regarding delivery of services and 

changing patient care needs 91

- Planned visits 

- Group visits 

- Automated relay of clinical information 

from home-based monitoring devices 

Organizational 

Supports 

Resources that influence the ability of an 

organizations to implement coordinating 

mechanisms.91, 310

- Co-location of care sites 

- Information systems (e.g., computerized 

decision support systems) 

- Staffing decisions 

- Incentives 
119 

Empirical evidence from outside of health care has shown that information requirement 

characteristics (interdependence, uncertainty, and complexity) correlate in predictable ways to 

organizational capacity (coordinating mechanisms such as grouping, linking, and operational 

processes). 130 Applying these concepts to the health care setting is largely limited to 

observational studies that have yielded somewhat mixed results. 89-91, 109, 135, 297, 309, 311, 312 Figure 

6 depicts the hypothesized relationships between the underlying situation or coordination 

problem (square box on left side of Figure 5) and some of the coordinating mechanisms (rounded 

corner box on the right side of Figure 5). 

Wagner’s Chronic Care Model as an Example of Organizational Design. To make some 

of these concepts more concrete, we describe how a commonly known model for effective 

chronic illness care reflects concepts of the organizational design framework. Wagner and 

colleagues have proposed and applied a model for that relies on “productive interactions” 

between an “informed, activated patient” and a “prepared, proactive practice team” to produce 

improved functional and clinical outcomes.187 The information processing requirements of the 

patient relate to the goal of making him or her well-informed and able to process information 

appropriately. Similarly, the practice team must be prepared through receiving adequate 

information. The information processing capacity can be titrated to fit each patient-practice team 

dyad’s information processing requirements, based on a range of coordinating mechanisms all 

pitched under the umbrella of organization of health care in Wagner’s model.149 

1. Community linkages are an example of structural linking in the organizational design 

terminology, and consisted of use of a designated case manager and creating interactive web 

sites. 

2. Self-management support takes the form of an operational process of standardization in the 

case of a tool kit with tracking forms and action plans. 

3. Delivery system re-design could reflect structural linking when telemedicine for rural 

patients is implemented, or grouping when nurse educator is included in a planned diabetes 

visit, or the operational process of monitoring with group visits. 

4. Decision support occurs as an operational process of adjustment in the case of a system that 

generates regular feedback for clinical teams on guideline compliance from registry data, or 

simply an organizational support to help facilitate other coordination mechanisms. 

5. Clinical information systems also reflect an organizational support. 

The examples provided for each of these five mechanisms come from a collaborative 

“Breakthrough Series” effort to innovate across 23 diverse health care organizations – including 

academic medical centers, community clinics, hospital-based programs, manage care, and safety 

net organizations.149 Other examples given could also be easily mapped to the organizational 

design concepts. 

Model 4: The Relational Coordination Framework 

From the management sciences field, Jody Gittell has introduced a framework of relational 

coordination to understand the dynamics present in teamwork or collaboration.103, 104 Relational 

coordination aims to focus attention on relationships between participants whose awareness of 

the relationship of their work to the overall goals and to others involved in patient care is crucial, 

particularly for service organizations like health care with highly uncertain, time-sensitive, and 
120 

interdependent activities. Relational coordination is characterized (and measured) by the 

following: frequency, timeliness, and problem-solving aspects of communication among 

participants in care; helpfulness; shared goals and knowledge; and mutual respect. Gittell has 

conducted several studies to explore the links between relational coordination, organizational 

design, and performance (quality and efficiency)103-105, 313 Figure 7 shows Gittell’s Framework 

of Relational Coordination, and illustrates some of the hypothesized linkages. In particular, 

variability in outcomes from different interventions to improve care coordination may be due in 

part to differences in the effectiveness of these interventions in improving relationships among 

interdependent clinicians.294, 313

Figure 7. Relational Coordination Framework 

Several studies have investigated the relational aspects of coordination. Relational 

coordination has been linked to higher patient-perceived quality of care and reductions in length 

of stay for joint arthroplasty in hospital orthopedic departments.104, 313 In the hospital setting, 

Shortell et al. found that higher reported quality of caregiver interactions in intensive care units 

was strongly associated with lower risk-adjusted LOS, lower nurse turnover, perceived technical 

quality of care, and perceived ability to meet family member needs, but was not associated with 

risk-adjusted mortality.126 Studies of nurse-physician collaboration by Baggs et al, also in the 

intensive care setting, suggest that better interprofessional collaboration as reported by nurses 

may be associated with better patient outcomes314 and provider satisfaction.315 Finally, in a study 

of nurse, respiratory therapist, and physician collaboration in neonatal intensive care units, lower 

rates of certain morbidities were associated with higher collaboration but varied by clinician 

group, while lower mortality rates were associated with better respiratory therapist-reported 

collaboration only. When the collaborative scores of all clinician groups were evaluated 

simultaneously, however, the relationship between collaboration and mortality failed to reach 

statistical significance.124

Organizational 

Design

Quality

Participants & Teamwork

Communication

Shared Goals &

Knowledge

Mutual Respect

Helpfulness Efficiency
121 

Summary of Concepts From Frameworks 

Table 18 summarizes the concepts from the four frameworks, organizing concepts into three 

general areas: baseline assessment of the setting, patient population, and other factors that might 

influence the amount of coordination needed; coordinating mechanisms related to each 

framework; and outcomes aimed for in each framework. Grouping the concepts into three main 

analytic areas may oversimplify the potential relationships between concepts. However, for 

those who are designing or evaluating a new intervention to improve care coordination, we 

recognize the need to have an analytic framework that provides a starting point (baseline 

assessment of current situation—depicted in each of the included figures of the conceptual 

frameworks by the boxes with square corners), options for interventions (coordinating 

mechanisms—depicted in each of the figures by boxes with rounded corners), and outcomes to 

monitor (depicted by shaded diamonds). Each of the concepts from the four frameworks applies 

to developing or studying a given approach to care coordination. 

Table 18. Summary of relationship of concepts across frameworks 

Concept (Framework) Example Corresponding Evaluation Question 

Baseline Assessment of Setting, Patient Population, and Other Factors 

Need for Coordination 

(Andersen Behavioral 

Framework) 

 Is there a need for coordination perceived by one or more of the participants 

(service-level decisionmakers: patient, nurse, physician, social worker, case 

manager, etc.; system-level decisionmakers: State Medicaid director, quality 

improvement manager in an integrated health care organization, etc.)? Are 

perceptions of fragmented care similar among participants? 

Predisposing 

Characteristics (as above 

Behavioral) 

 What characteristics are not easily amenable to change and might affect either 

perception about the need to coordinate care or coordination behaviors? Is it 

feasible to measure these and find out if they are indeed effecting perceptions or 

behaviors? Who would have the ability to make changes to these characteristics? 

Enabling Resources 

(Behavioral) 

 What resources are available to make coordination easier? What resources are 

missing, resulting in barriers to coordination? Is it feasible to change these by an 

intervention or investment? 

Structures of Care 

(Donabedian) 

 What care settings are relevant to coordinating care for a particular patient or 

panel of patients? Or group of beneficiaries or health plan enrollees? 

Information Requirements 

(Organizational) 

 How are participants dependent upon each other for information? How complex 

are patient care activities, and what are the informational consequences? How 

rapidly is information needed for patient care activities? How much uncertainty is 

involved in patient care for the particular population of patients? 

Coordinating Mechanisms 

Relational Coordination How productive is communication among participants in care? Are there shared 

goals and knowledge? If measures of relationship coordination are low, what 

interventions are available to increase awareness of roles and mutual respect (e.g., 

enhance relational coordination)? 

Organizational Design 

Options (Organizational) 

 What options are feasible for providing information processing capacity to match 

the requirements identified in the preceding step (e.g., enhance informational 

exchanges)? Is it feasible to change how the participants are grouped? What 

structural linking options are feasible and most likely to match the information 

processing requirements? What operational processes and supports would be most 

appropriate to change given the needs? 

Coordination Processes 

(Donabedian) 

 Same as preceding two coordinating mechanism concepts, plus: 

What care delivery processes need to be coordinated? 
122 

Table 18. Summary of relationship of concepts across frameworks (continued) 

Concept (Framework) Example Corresponding Evaluation Question

Outcomes of Care Coordination

Coordination of Health 

Services (Behavioral) 

 What is the evidence that participants’ behaviors have coordinated care? 

Patient Outcomes 

(Donabedian) 

 What improvements in patient outcomes are potentially related to coordinating 

mechanisms implemented or other changes in structure or enabling resources? 

Coordinated Care 

(Organizational) 

 To what extent are the coordinating mechanisms congruent with the needs of the 

participants to achieve desired patient outcomes at a reasonable cost? 

Thus, a general approach to applying concepts from theoretical frameworks involves: 1) 

assessment of the needs for coordination by reviewing baseline characteristics for a given 

practice setting and patient population, 2) identification of the options for improving 

coordination by reviewing potential coordination mechanisms and considering their fit with the 

demands of the particular circumstances, 3) selection and implementation of one of the 

alternatives, 4) evaluation to determine effects on coordination and outcomes of care, and 5) 

iteration if needed to test alternative solutions. Such application of the frameworks presented in 

this chapter may provide a useful way for systems level decisionmakers to characterize and 

assess specific approaches embedded in demonstration projects and used within health care 

delivery organizations. Likewise, the components list (described in Chapter 3) offers an 

approach for decomposing interventions at the clinician-patient service delivery level. 

Measures Related to Care Coordination 

Assessments of care coordination interventions report five types of measures: patient 

outcomes, cost outcomes, care delivery process measures, coordination mechanism measures, 

and patient/family perception of coordination. Both patient and cost outcomes measures

(mortality, morbidity, functional status, costs, etc) are the end goals for improvements in care 

coordination. Assessing these outcomes is important in all evaluations of care coordination 

interventions. Care delivery processes generally capture the occurrence of recommended care 

activities that are expected to arise from appropriately coordinated work. Measures of care 

delivery processes are often intended to identify whether care practices (e.g., patient follow-up 

visits, intensification of medication) occurred in accordance with recommended guidelines.4, 132, 

316 At the same time, they provide limited insight into the processes that facilitated the 

appropriate performance of these activities. In addition, guidelines upon which these measures 

are based are often disease-specific, and provide little information about how care is negotiated 

to manage multiple conditions.317

The last two categories of measures (coordination mechanisms and patient perception of 

coordination) relate more specifically to care coordination. 

Table 19 illustrates examples of some of these measurement tools found in the literature and 

how they map to concepts from the frameworks. The measures in the table are subsidiary to 

outcomes measures, but are important for intervention design to determine what features of a 

design contribute to improvements in coordination. These measures need to be used along with 

outcomes measures to provide a full picture of the effectiveness of a care coordination 

intervention. The subsequent sections highlight some of the important methodological 

challenges in measuring concepts specifically related to care coordination. 
123 

Coordination mechanism measures reported in the literature focus on either measurement of 

information exchanges, relational coordination among participants, or enabling resources present 

in the care setting. Information exchange and relational coordination measures ideally assess 

both the occurrence of information transfer among participants and recognition or awareness of 

relevant information by the decisionmaker. Such measures would help test whether a particular 

coordinating mechanism used in organizational design matched the information-processing 

requirements of the patient care situation. Similarly, measures of relational processes would be 

able to assess both the occurrence of interaction among participants, and common understanding 

of care activities and individual roles in delivering care to help identify issues related to 

relational coordination. 

Direct observation of these processes poses significant methodological and data collection 

challenges, and indirect (but more easily gathered) measures have therefore typically been used. 

Measures of clinical information exchange include use of medical record audits to identify 

written or reported evidence of information transfer (e.g., note in medical record of physician 

knowledge of other physician’s involvement in patient care96, 143). Measures of relational 

processes have often relied on self-report by team members, which may or may not reflect actual 

collaborative practices. Further research is needed to understand how differences in perceptions 

of collaboration150, 160, 162, 314 and specific components of collaborative interactions136 may affect 

delivery of care. 

Development of measures for interprofessional collaboration has also generally been 

conducted within the acute care settings where either teams or organizational units are welldefined. More recent efforts have attempted to measure collaboration in other settings, such as 

integrated long-term care settings.129 Given existing methodological and data collection 

challenges in measuring collaboration in well-defined units or teams, it is as yet unclear how 

clinician report-based measurement efforts may be extended to settings where interdependent 

clinicians are more loosely affiliated, not aware of one another, or not easily identified. 

Patient-reported perceptions of coordination provide a proxy measure for the overall 

coordination performance of providers. In the setting of care transitions and often fragmented 

chronic illness care, patients are recognized as potentially the only “common thread” linking 

interdependent clinicians and settings318 and may represent the only perspective (and data 

source) from which coordination of care may be measured. These measures are also more 

aligned with a patient-centered focus in health care quality. They can be meaningful, for 

example, in identifying that patients are getting conflicting advice that is not resolved (e.g., poly 

pharmacy). However, patients are unlikely to be aware of many of the specific activities 

coordinated in their care.94, 162 As a result, these measures may provide limited value in 

identifying and monitoring the specific processes that interventions to improve coordination 

might seek to change. 

Given the relative strengths and limitations of these approaches to measurement, it seems 

likely that use of a combination of these measurement approaches within studies (e.g, clinician 

and patient report of coordination, direct and indirect measures) are needed to achieve a more 

comprehensive understanding of care coordination. 

For example, an intervention designer testing a collaborative care model might want to use 

two instruments to assess the perspectives of different participants—one for the patient and 

another instrument for the providers of care—in order assess whether the intervention functioned 

as expected. Without such an assessment, it is impossible to tease apart a lack of effectiveness in 

achieving collaboration versus a lack of impact on patient outcomes from effective collaboration. 
124 

Thus, during the evaluation phase for a new intervention, the implementer could survey patients 

with Glasgow et al’s “Patient Assessment of Chronic Illness Care” instrument, which includes 

items such as “Over the past 6 months, I was asked how my visits with other doctors were 

going” and “I was satisfied that my care was well organized”. For members of the collaborative 

care team, the implementer could use or adapt the survey instrument developed by TemkinGreener and colleagues to assess interdisciplinary team processes and performance, which 

includes items related to relational coordination such as “When team members talk, we 

understand each other,” and “Others in my team have a good understanding of patient care plans 

and goals.” If the decisionmaking between two types of team members (e.g., nurse and 

physician) is considered particularly important, Baggs’ “Collaboration and Satisfaction About 

Care Decisions (CSACD) would be another choice for an instrument. The findings from these 

surveys could help the intervention designer determine weaknesses in the intervention, that once 

ameliorated would increase the chances that the intervention would improve patient outcomes. 

Table 19. Instruments and measures related to care coordination mechanisms or patient/family 

perception of coordination 

Reference Instruments 

and 

Measures 

Objective* Domains or Scales Framework 

Concept** 

Perspective 

Baggs & Ryan 

1990;319

Baggs 1992314

Decisions 

About 

Transfer 

To measure the 

collaboration and 

satisfaction involved with 

making a specific decision 

about a specific patient 

Collaboration; 

Satisfaction 

Relational 

coordination 

Nurse; 

Physician 

Baggs 1994315 Collaboration 

and 

Satisfaction 

About Care 

Decisions 

"To measure nursephysician collaboration and 

satisfaction about care 

decisions in intensive care 

units" 

Collaboration 

attributes (planned 

together; open 

communication; 

decisionmaking 

responsibilities shared; 

cooperated; nursing 

and medical concerns 

about patient's needs 

actively represented; 

decisionmaking was 

coordinated) 

Satisfaction attributes 

(decisionmaking 

process; decision) 

Relational 

coordination 

Nurse; 

Physician 

Bonomi 

2002189

Assessment 

of Chronic 

Illness Care 

"To help organizations 

evaluate the strengths and 

weaknesses of their delivery 

of care for chronic illness in 

six areas: community 

linkages, self-management 

support, decision support, 

delivery system design, 

information systems, and 

organization of care"; 

"assist teams in identifying 

areas for improvement for 

chronic illness care" 

Health Care 

Organization; 

Community Linkages; 

Self-Management 

Support; 

Delivery System 

Design; 

Decision Support; 

Clinical Information 

Systems 

Structure/ 

Enabling 

Resources 

Organizational 

Teams 
125 

Table 19. Instruments and measures related to care coordination mechanisms or patient/family 

perception of coordination (continued) 

Reference Instruments 

and Measures 

Objective* Domains or Scales Framework 

Concept** 

Perspective 

Cassady 

200094

Primary Care 

Assessment 

Tool - Child 

Edition 

To "[assess] the adequacy 

of key characteristics of 

primary care services for 

children and youth" 

Longitudinality - 

relationship; 

First contact - 

accessibility; 

Comprehensiveness - 

services available; 

Comprehensiveness - 

services provided; 

Coordination 

Patient 

perception 

Parent 

Coleman 

2005318

Care 

Transitions 

Measure 

To "[measure] the quality 

of preparation for care 

transitions" from the 

patient's perspective 

Critical understanding, 

Preferences, 

Important, 

management 

preparation, 

Care plan 

Patient 

perception 

Patient 

Cooley 200395 Medical Home 

Index 

To "[provide] a point-intime determination of 

'medical homeness'" in 

pediatric primary care 

practices 

Organizational 

Capacity; 

Chronic Condition 

Management; 

Care Coordination; 

Community Outreach; 

Data Management; 

Quality Improvement 

Structure/ 

Enabling 

Resource 

Lead 

physician; 

Staff 

member; 

Site visit; 

interview 

Fletcher 

198496

No name (chart 

review 

measure) 

"To develop a measure of 

[the process of integrating 

various episodes of care]" 

Continuity; 

Coordination 

Information 

exchange 

Medical 

record 

Flocke 199798 Components of 

Primary Care 

Index 

"To measure seven key 

aspects of the delivery of 

primary care from the 

perspective of patients 

visiting their family 

physician" 

Interpersonal 

communication; 

Physician's 

accumulated 

knowledge of the 

patient; 

Coordination of care; 

Patient's preference for 

their regular physician 

Patient 

perception 

Patient 

Glasgow 

2005106

Patient 

Assessment of 

Chronic Illness 

Care 

"To assess the extent to 

which patients with 

chronic illness receive 

care that aligns with the 

Chronic Care Model" 

Patient Activation; 

Delivery System 

Design / Decision 

Support; 

Goal Setting; 

Problem-solving / 

Contextual 

Counseling; 

Follow-up / 

Coordination 

Patient 

perception 

Patient 
126 

Table 19. Instruments and measures related to care coordination mechanisms or patient/family 

perception of coordination (continued)

Reference Instruments 

and Measures 

Objective* Domains or Scales Framework 

Concept** 

Perspective 

Grimmer 

2001320

“PREPARED” 

(Prescriptions, 

Ready to reenter 

community, 

Education, 

Placement, 

Assurance of 

safety, Realistic 

expectations, 

Empowerment, 

Directed to 

appropriate 

services) 

"To gather information on 

community stakeholder 

perceptions of the quality 

of the process and 

outcome of discharge 

planning activities 

undertaken in the acute 

hospital setting." 

Process domains: 

information exchange; 

receipt of medication 

information; 

preparation for coping 

post-discharge; control 

of discharge 

circumstances 

Patient 

perception 

Consumers 

Hojat 1999161 Attitude scale 

measuring 

physician-nurse 

collaboration 

(revised 

Jefferson 

Survey of 

Attitudes 

Toward 

Physician-Nurse 

Collaboration) 

To "[measure] attitudes 

toward physician-nurse 

collaboration" 

Shared educational and 

collaborative 

relationships; 

Caring as opposed to 

curing; 

Nurse's autonomy; 

Physician's authority; 

Relational 

coordination 

Nurse; 

Physician 

McGuiness & 

Sibthorpe 

2003119

Client 

Perceptions of 

Coordination 

Questionnaire 

 To measure patient 

perceptions of 

coordination of care, 

involving multiple 

services delivered by 

different agencies over 

time 

Identification of need; 

Access to care; 

Patient participation; 

Patient-provider 

communication; 

Inter-provider 

communication; 

Global assessment of 

care coordination 

Patient 

perception 

Patient 

Morita 2004321 Care Evaluation 

Scale 

"To [directly measure] 

the bereaved family's 

perception of the 

necessity for 

improvement in 

structural/procedural 

aspects of palliative care" 

Subscales: Physical 

care (by physician, by 

nurse); psychoexistential care; help 

with decisionmaking 

(for patient, for 

family); environment; 

family burden; cost; 

availability; 

coordination and 

consistency 

Patient 

perception 

Family 
127 

Table 19. Instruments and measures related to care coordination mechanisms or patient/family 

perception of coordination (continued)

Reference Instruments 

and Measures 

Objective* Domains or Scales Framework 

Concept** 

Perspective 

Radwin 

2003322

Oncology 

Patients' 

Perceptions of 

the Quality of 

Nursing Care 

Scale 

To "[measure] the quality 

of cancer nursing care 

from the patient's 

perspective" 

Responsiveness, 

Individualization, 

Coordination, 

Proficiency 

Patient 

perception 

Patient 

Safran 1998323 Primary Care 

Assessment 

Survey 

To operationalize and 

measure primary care 

performance 

Accessibility, 

Continuity; 

Comprehensiveness; 

Integration; 

Clinical Interaction; 

Interpersonal 

Treatment; Trust 

Patient 

perception 

Patient 

Shortell 

1991324

ICU NursePhysician 

Collaboration 

Questionnaire 

To examine perceptions 

of nurses and physicians 

on collaborative 

interactions in an 

intensive care unit 

Coordination Relational 

coordination 

Nurse; 

Physician 

Starfield 

1979128

No name "To determine the extent 

to which the medical 

record contained evidence 

of coordination of care" 

Leadership; 

Organizational culture; 

Communication; 

Coordination; 

Problem 

solving/conflict 

management; 

Team cohesiveness 

Information 

exchange 

Medical 

record; 

Direct 

observation 

TemkinGreener 

2004129

Interdisciplinary 

team 

performance in 

LTC and PACE 

settings 

To "[assess] 

interdisciplinary team 

performance in long-term 

care settings" 

Leadership; 

Communication; 

Coordination; Conflict 

Management; 

Team cohesion; 

Perceived Team 

Effectiveness 

Relational 

coordination 

Care Team 

Members 

Weiss 1985156 Collaborative 

Practice Scales 

"To assess the degree to 

which the interactions of 

nurses and physicians 

enable synergistic 

influence of patient care" 

Nurse scale factors: 

direct assertion of 

professional 

expertise/opinion; 

active clarification of 

mutual responsibilities 

in patient care; 

Physician scale 

factors: 

acknowledgement of 

nurse's contribution to 

patient care, consensus 

development with 

nurses regarding 

mutual responsibilities 

and patient care goals 

Relational 

coordination 

Nurse; 

Physician 
128 

Table 19. Instruments and measures related to care coordination mechanisms or patient/family 

perception of coordination (continued)

Reference Instruments 

and Measures 

Objective* Domains or Scales Framework 

Concept** 

Perspective 

Zillich 2005154 PhysicianPharmacist 

Collaboration 

Instrument 

"To measure physicians' 

views of physicianpharmacist collaborative 

relationships" 

Initial instrument: 

Collaborative Care; 

Commitment; 

Dependence 

Symmetry; 

Bidirectional 

communication; Trust; 

Initiating behavior; 

Conflict resolution. 

Refined instrument: 

Trustworthiness; Role 

Specification; 

Relationship Initiation 

Relational 

coordination 

Physician 

*Some objectives do not explicitly describe a care coordination element, but the assessment instrument includes 

questions about care coordination. 

**The developers of the instruments do not describe their measures in terms of concepts from the frameworks 

evaluated in this Chapter. We have reviewed their questions or instrument response items, and provide a rough 

categorization that reflects the majority of the questions pertinent to coordination. If instrument items focus on 

understanding of participants’ roles and teamwork, we use the category “Relational coordination” based on Gittell’s 

model. If the instrument items relate to the flow of information, then we use the category “Information exchange” 

based on the organizational theory framework. Two instruments assesses structures of care and resources available, 

and is categorized accordingly. The remaining measures focus on patient perceptions of coordination (as well as 

other areas of care in many cases). 

5D. Summary Answers to Key Questions 

Research Question 8: What Concepts Are Important To Understand 

and Relate to Each Other for Evaluations of Care Coordination? What 

Conceptual Frameworks Could be Applied To Support Development 

and Evaluation of Strategies To Improve Care Coordination? 

We identified four well-established frameworks that complement each other in terms of 

developing and studying care coordination interventions and programs. Taken together, the 

frameworks include a dozen concepts generally fitting into one of three domains: baseline 

assessment of the specific patient care situation, coordination mechanisms, and outcomes of care. 

The exact relationships between concepts (e.g., how much of the variation in use of health 

services is explained by enabling resources like availability of a clinic) is fairly well-developed 

for the original specification of the frameworks; however extensions of these frameworks to care 

coordination (e.g., how much of the variation in care coordination behaviors by the participants 

is related to predisposing characteristics like attitude toward collaboration) will need to be 

studied carefully. 

These frameworks for care coordination provide evaluators of new interventions with a guide 

to understanding the relationships and connections between an intervention and patient 

outcomes. Developers and evaluators of interventions to improve coordination need to ask: 
129 

• What are the coordination needs related to patient care? At the service level, this might 

entail an initial assessment of an individual patient that determine what needs to be 

coordinated based on the level of complexity and uncertainty related to the patient’s clinical 

condition, insurance coverage, preferences, family support and other situation-specific 

factors. At the system level, this question could be posed for a population with an 

assessment of the range of coordination needs anticipated. 

• Who are the participants in care, and how are they dependent on each other for a given care 

situation? At the service level, the participants might be a primary care physician, office 

staff, and an adult patient who has several chronic illnesses and is also seeing two specialists. 

At the system level, care of a targeted group of high cost Medicare beneficiaries may include 

numerous participants, with varying levels of dependence on each other for information and 

services. 

• What are the enabling factors already in place (e.g., personnel resources, information 

systems)? Does the intervention or a part of it aim to add a new enabler (e.g., quality 

improvement strategy such as provider reminders) expected to improve coordination? 

• What are the predisposing factors that influence the motivation of those involved in 

coordination (e.g., attitudes, incentives)? 

• How is the intervention expected to change the coordination process of informational 

exchange? In other words, how does the intervention movement of necessary information 

across interfaces, such as different settings of care? 

• How is the intervention expected to change the coordination process of relational awareness? 

In other words, what does the intervention do to improve participant’s understanding of the 

relationship of one individual’s work to the overall goals and to that of others involved in 

patient care? 

• How are the interactions of these factors and coordination processes expected to affect 

clinical processes and patient outcomes (e.g., what is the hypothesis about why the 

intervention will work)? 

Research Question 9: What Measures Have Been Used To Assess 

Care Coordination? 

Studies of care coordination have evaluated patient outcomes, including changes in mortality, 

symptoms, unemployment, staying connected to services, and adherence to medication. Cost 

and utilization outcomes, including hospitalizations, emergency department visits, and clinic 

visits were included in a number of studies. Also, patient and family satisfaction were reported 

in some instances. 

We also separately searched the literature for instrument development related to care 

coordination, and found 20 instruments and approaches. About half of the instruments are 

targeted at patient and family members, and ask about perceptions of care, including items about 

coordination (e.g., “treatment was planned with appropriated considerations of previous course 
130 

of the disease” ,321 “told me which nurse was primarily responsible for coordinating my care”).322

Two of the instruments derive their data from chart reviews to assess the information exchanged 

between physicians. Seven instruments survey physicians or members of a defined care team to 

assess collaboration and teamwork processes and performance. Two instruments evaluate 

resources and structures (e.g., community linkages) that support care coordination. One of these 

instruments is for systems that care for adults with chronic illness, and the other is for primary 

care practices that have adopted a “medical home” approach to pediatric care. 

The measurement field related to care coordination is in the early phases of its development. 

It is as yet unclear what approach or combination of approaches to measurement will adequately 

capture the processes driving an intervention’s effect, particularly outside well-defined care 

settings, where the challenges for coordination are most salient to the patient and families. 

Research Question 10: How do These Frameworks Relate to Quality 

Improvement Strategies Evaluated in the Previous Closing the Quality 

Gap Series Reports? 

The IOM Priorities Report6 highlighted care coordination as a cross-cutting topic, meaning 

that it related to the other areas prioritized for national action. As a result, the relationship 

between the conceptual frameworks for care coordination and our previous work on quality 

improvement strategies for some of the IOM priority conditions (e.g., hypertension, diabetes, 

asthma, etc.) merits some exploration. The quality improvement strategies evaluated in the 

previous reports from our Closing the Quality Gap series include patient education, self 

management, provider education, provider reminders, audit and feedback, relay of clinical data, 

organizational change (including disease management and case management), financial and 

regulatory incentives and are relevant to care coordination.325 Most of these strategies have been 

shown to improve health outcomes in randomized controlled trials or other fairly rigorous 

comparative study designs. They are often used in packages of several strategies together, so 

assessing the essential component or components is often not feasible. 

These strategies share the objective of improving care through changing patient, provider or 

organizational behavior. To the extent that they influence behavior, they are most easily mapped 

into the Andersen behavior framework as changes to predisposing or enabling factors (e.g., 

financial incentives to alter a predisposing characteristic—one’s underlying motivation, or 

provider education to enhance skills as an enabling resource for improving quality of care). In 

addition, many of the strategies relate to the organizational design and relational coordination 

frameworks (e.g., provider reminders as an operational process that improves information 

transfer; patient education and self-management aimed at enhancing communication between 

patient and physician). Finally, the organizational change quality improvement strategies are 

synonymous with care coordination interventions (e.g., case management, disease management, 

creation of multidisciplinary teams), based on our working definition. 
131 

Chapter 6. Conclusions 

 

This Report describes definitions, ongoing programs, systematic reviews of interventions, 

and conceptual frameworks related to care coordination. The field of care coordination may be 

thought of narrowly or broadly. Based on discussions with decisionmakers with diverse views of 

the field, we decided that an important first step in building an evidence base related to care 

coordination required an overview approach instead of a targeted literature review of primary 

studies representing only a slice of the full picture. For example, some decisionmakers are 

particularly interested in the role of self-management in coordinating and improving health care, 

while others are interested in specific approaches such as disease management. All agree, 

however, that care coordination needs to be defined in order to assemble pertinent evidence, that 

a critical analysis of evidence from systematic reviews related to care coordination would reflect 

the IOM’s categorization of care coordination as a cross-cutting priority applicable to many 

health conditions and situations, and that more conceptual thinking could help guide the design 

and evaluation of care coordination programs and interventions. Our goal was to address these 

common interests, summarize findings of relevance now to both service level and system level 

decisionmakers, and recommend future research resulting from our work. 

Improving Care Coordination 

Our findings highlight the need for reaching consensus on definitions, conceptual models, 

and outcome measures related to care coordination and the necessity of continued research to 

evaluate the value of different coordination efforts. While the research community responds to 

these needs, patients and providers recognize that improved coordination is an immediate and 

urgent problem. The 2006 Commonwealth Fund survey reported that 92% of patients felt that it 

was “somewhat” or “very important” to have one doctor, or one place, responsible for primary 

care and coordinating care and 96% percent of patients said it was “somewhat” or “very 

important” that care from different doctors be well coordinated.326 Physicians surveyed by the 

Commonwealth Fund in 2003, indicated that patient medical records, tests, or other relevant 

clinical information were not available at the time of scheduled patient visits 72% of the time and 

only 34% of physicians reported receiving timely information about referrals.327 How does this 

report inform the patients, providers, and system level decisionmakers in today’s healthcare 

system? 

We found that care coordination interventions improved important patient outcomes in 

different diseases across a broad spectrum of clinical settings. Systematic reviews provided 

evidence of benefit with multidisciplinary teams (including those involved in assertive 

community treatment, collaborative care, shared primary-specialty care and other arrangements), 

case management, and disease management. Multidisciplinary team interventions have been 

shown to reduce mortality and dependency in stroke patients; reduce mortality and hospital 

admissions in heart failure patients; improve service continuity for severely mentally ill patient; 

and reduce symptoms for terminally ill patients. Some evidence suggests that a deliberate effort 

to coordinate among team members (e.g., regular meetings) is a determinant of improved 

outcomes.219 Case management as a care coordination strategy appears to improve patient 

outcomes for patients who have mental health problems, heart failure or diabetes. Close patient 

monitoring was identified as an important component in two reviews.233, 269 Disease 
132 

management programs with coordination elements also appear to be effective in improving 

patient outcomes, especially for patients with depression or diabetes. While these and other care 

coordination interventions have been reported in systematic reviews covering other coordination 

challenges (e.g., transitions of care, other diseases, and specific patient populations such as the 

elderly or homeless people), there is insufficient evidence to draw any conclusions in these other 

instances. 

Reviewing the literature from the perspective of the patient, the provider (or service delivery 

level) and the system level decisionmaker provides some guidance for the immediate future. 

From the perspective of system level decisionmakers, probably the most important lesson from 

the literature reviewed is that the current evidence does not support one single model of 

coordination. The lack of consensus regarding definitions and measures, and the paucity of data 

on the cost effectiveness of different interventions, limits the ability to compare the value of 

different care coordination efforts. Policymakers and decisionmakers at the system level must 

exercise caution before investing significant resources to support interventions without evidence 

demonstrating their value, despite the fact that these interventions may seem to “just make 

sense.” In the absence of strong evidence supporting specific coordination interventions, system 

level decisionmakers should consider supporting pilot programs while awaiting the results of 

larger, national studies such as the Medicare Coordinated Care and the Physician Group Practice 

Demonstration projects. 

From the perspective of the patient, the literature reviewed provides some information for 

specific patient populations. For patients with congestive heart failure, the evidence supports 

enrollment in some type of coordinated care program (disease management, multidisciplinary 

team care, or case management). The majority of the reviews support formal coordinated care 

programs for patients with diabetes mellitus, depression, and other mental health illnesses. 

Patients hospitalized with acute stroke benefit from teams which coordinate discharge planning 

and postdischarge treatment plans. Patients in these clinically defined populations should 

consider care coordination programs as one element of evidence based therapy in their treatment 

regimens. 

The evidence is not as clear for other patient populations that have obvious coordination 

needs, such as patients with multiple complex medical problems, the frail elderly living 

independently, patients transferring between care settings, or physically disabled persons. There 

are many models of care for these populations but few systematic reviews demonstrating the 

benefit of one coordination intervention over an alternative. However, these patients’ needs are 

real and immediate and they must navigate today’s health care system, while awaiting overall 

improvements in care coordination at the system level. For these patients identifying the 

components of coordinated care and adopting features of care coordination which can be 

initiated by the patient and caregivers may offer some assistance to their immediate needs. 

Providers and decisionmakers at the health service delivery level are caring for patients with 

increasing needs for coordination services in a system that is progressively becoming more 

fragmented. Physicians perceive that time constraints are a major barrier to patient care.328

Coordinating care for patients takes time; time that is typically not reimbursed. As the 

population ages, as the number of people with multiple chronic medical problems increases, and 

as patients see more doctors and receive care at a greater number of healthcare settings, the need 

to coordinate care will continue to increase. This increase in need is occurring in an 

environment in which cost containment efforts result in decreased access to social support 
133 

services. While the need for coordination increases, healthcare providers frequently lack the 

infrastructure and resources to respond to their patient’s needs. 

Some components of care coordination can be adopted by providers at minimum cost. 

Routinely assessing coordination needs for patients at high risk may offer an opportunity to 

proactively address a need and avert a potential problem, e.g., notifying a family member to 

anticipate that the patient will need extra help at home following a scheduled hospital admission 

may prevent a delay in hospital discharge. Communication between providers and between care 

settings is a major problem and providers can assume the responsibility that referral letters and 

discharge summaries are sent in a timely manner. The current lack of interoperable electronic 

medical records greatly complicates this problem. Providers should also consider establishing 

communication links with community services and maintaining an inventory of these services. 

Providers should enroll willing patients in established care programs in which the evidence 

demonstrates improved outcomes, e.g., patients with CHF should be encouraged to enroll in 

coordinated care programs. As research in this field evolves, providers can work collaboratively 

with system level decisionmakers to adopt care coordination models that have demonstrated 

improved patient outcomes. 

The table below lists suggestions to improve care coordination from the perspective of the 

patient, the provider, and the decisionmaker at the system level. Where the evidence exists based 

on systematic reviews, that information is presented and noted explicitly as evidence-based using 

bold-faced type. Many of the other approaches to improving care coordination are drawn from 

various intervention activities encountered in the research for this report, and should not be 

construed as having clear evidence of a benefit. They are selected as activities that can be done 

in a short time frame and possibly with minimal resources. This table is designed to help those 

who ask, “What can I do today to improve coordination for myself, my family or my patients?” 
Table 20. Suggested approaches for improving care coordination 

Coordination Component

Patient Provider 

Identification and assessment of need for coordination services 

- Patients or caretakers should tell providers about their level of confidence related to coordinating various care services and when transferring care between settings - Some patients will benefit from care coordination interventions tailored to specific diseases (CHF, DM, depression, mental illness), and should ask their health plan or physician about these services 

- Identify patients who are likely to have increased needs for coordination (complex medical or social problems, multiple healthcare providers involved in care, services received at multiple sites, and patients with specific diseases such as CHF, DM, and depression, mental illness) - Assess medical and social services required for care (consider geriatric assessment in high risk populations) 

Alert providers of high service hospitalizationsoutpatient visits

Role identification in care coordination 

- Patient identifies family, friends, caregivers and medical providers who are part of the patient’s medical “home” and ensures that the principal source of care is aware of all members in the home. - If the patient is unable to participate with care coordination activities, an alternative caregiver should be identified and the patient must document his/her permission for the caregiver to receive medical information on behalf of the patient 

- With the patient, identify which clinician is the principal source of care - Identify the healthcare team members who will be responsible for coordinating services and communicating with the patient and make sure everyone understands their distinct roles 

Ensure provideravailable resourpopulations (caworkers, diseasand how to acce

Care planning Patient and family communicate with 

principal source of care to identify healthcare priorities (these may differ from provider identified priorities) 

- Coordinate care plans and ensure that plans do not conflict, e.g., patients with CHF and severe COPD who receive beta blocker prescriptions for treatment of CHF by one physician but are instructed by another physician to avoid beta blockers because of their COPD - Develop clear follow-up plans 

Partner with cliplanning tools a(decision suppoetc) 

134
Table 20. Suggested approaches for improving care coordination (continued) 

Coordination Component 

Patient Provider 

Communication Active participation in communication: 

know how to contact principal source of care, call prior to scheduled visits to ensure necessary information is available to clinicians (especially when being referred to another provider) 

- Improve information exchange between providers and between settings. Provide patient education and communicate clearly regarding goals of referrals - Pre-appointment management: clinic staff ensure necessary medical records are available in advance of scheduled appointments - Consider increased use of telephone and electronic information transfer to communicate with patients 

Support timely information (deturnaround timefax/electronic trIdentify unreliapoints (hospital communication services and metest approaches organizational d5) to improve inthose points 

Implementation of coordination interventions 

- Patients with CHF should strongly consider enrolling in established disease management/care coordination 

programs if these programs are available - Patients with DM or depression should consider enrolling in these programs - Patients with mental illness may wish 

to consider enrollment in a care management program although the design of the program appears to be of greater importance than in the other disease specific programs reviewed in Chapter 4 

- Consider linking patients with care coordination programs or participating in team/collaborative approaches that show improved outcomes from systematic review evidence (see tables in Chapter 4 for CHF, 

DM, mental illness, including depression) - Patients hospitalized with CVA should receive consultation with coordinated care programs if available 

Offer care coor(including ongopossible) for clievidence (see tCHF, DM, medepression, paCVA)

Monitoring coordinating activities 

Patient and family/caretaker communicate satisfaction or problems with coordinating efforts 

Care coordinator (case manager, MD, advanced practice RN) identify strengths or barriers to coordination efforts 

Boldface type indicates evidence-based interventions, and regular type indicates that the suggestion is based on current efforts, but has not been evalua

135
136 

Recommendations for Future Research 

From our literature review, it is clear that future studies evaluating the effectiveness of care 

coordination interventions should explicitly define the care coordination intervention being 

evaluated. Much related terminology lacks standard definitions, leading to confusion about 

whether various approaches work. Furthermore, details of the specific interventions should be 

provided to enable comparisons and synthesis across studies. Further research should include 

analyses of the effects of specific care coordination components (e.g., mechanisms of 

coordination, task-specific characteristics) to determine if any particular component affects the 

effectiveness of the intervention. 

Similarly, more research is needed to develop an understanding of conceptual frameworks to 

guide reporting of key variables. At this point, systematic reviewers have not been able to adopt 

a standard approach to evaluating care coordination interventions. Often this information is 

missing from the primary studies as well. Ideally, investigators would want to know what to 

describe and assess, and further theoretical work in this area may be helpful. Organizational 

theory suggests that this detail is vital to properly design interventions and programs that match 

the information-processing demands of the specific situation. The purpose of our review of 

several theories (Chapter 5) was to show the relevance of models from different fields to care 

coordination interventions. For example, there is no doubt interplay between patient need for 

coordination, level of fragmentation present in a particular setting, and any coordination 

intervention, but what is the best approach to conceptualize and study such interactions? More 

research is needed to determine theories that will be potentially useful to care coordination 

intervention design.329 

Concurrently with theoretical work, since some argue that the need for it in this area is 

unproven,330 other research methods might be used to reach consensus about a common set of 

components that should be described any time an evaluation of a care coordination intervention 

is reported. We developed both a working definition and a list of components of care 

coordination to facilitate our review and analysis. The working definition allowed us to capture 

a broad range of interventions. We found application of the components list difficult due to the 

limited level of detail available in the systematic reviews. Future research might map the 

components from our list or that of others to interventions described in primary studies in order 

to define a common list, and to determine inter-rater reliability. 

Determining the effectiveness of care coordination also requires more research on measures 

of care coordination. Assessing whether an intervention improves patient outcomes or lowers 

costs is the main goal of effectiveness studies. However, other coordination-oriented measures 

such as those that assess relational coordination, information exchange, enabling resources, and 

patient perceptions of coordination are important for refining interventions when they do not 

work. More research is needed on the validity of these measures, and about the relationship of 

these coordination-centric measures to outcomes of care. In addition, new measures need to be 

developed for areas that are not yet covered adequately (e.g., patient utilities/preferences for 

coordination, intensity of intervention). 

Much of the work related to care coordination occurs outside of the research paradigm. 

Further research on observational study designs appropriate for this area is needed, and could 

build upon work in quasi-experimental methods, including those applied in this field.59 The 

evaluations of the Medicare demonstration projects look promising and include rigorous 

experimental and observational designs. Smaller-scale quality improvement efforts may lack 
137 

appropriate control groups for meaningful evaluations, and yet, development of methods to learn 

more from practical implementations seems particularly important for the area of care 

coordination. 

Another promising area for additional research is to test whether interventions that work in 

one setting are applicable to another setting. Some of the lessons learned in one clinical domain 

(e.g., geriatric evaluation and management approach, comprehensive community-based treatment 

programs for the mentally ill) may be relevant to other areas (e.g., stroke patients, children with 

special needs). Our review of systematic reviews offers a list of possible interventions, many of 

which are currently used more intensively in specific clinical domains. 

Finally, there is limited information at the systematic review level for some clinical domains 

and some types of interventions. It is likely that primary studies have been conducted on 

coordination of care for children with special needs, but the systematic review literature has not 

addressed this area yet.*

 Other areas may be lacking primary studies, though ripe for future 

research and even new approaches. For example, a recent study applied complexity science to 

identify coordination issues (e.g., difficulties encountered by a complex pediatric patient and 

family when a CT scan appointment was cancelled) and develop potential solutions (e.g., foster 

relationships between families and schedulers to support contingency planning when emergency 

scans displace scheduled appointments).331 

The study of care coordination is challenging. Nonetheless, the impressive improvements in 

outcomes that were documented in the systematic reviews included in our report indicate that 

care coordination can work, and that appropriately designed studies can identify these 

improvements. 

 

*

 Paul Wise and colleagues from the Stanford-UCSF Evidence-based Practice Center have prepared a White Paper 

for AHRQ on Care Coordination in Children with Special Health Care Needs, which will be published soon and will 

help fill this gap. 

139 

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List of Acronyms/Abbreviations 

Acronyms/Abbreviations Definition 

AAFP American Academy of Family Physicians 

ACP American College of Physicians 

ACT Assertive Community Treatment 

AGS American Geriatric Society 

BIPA Medicare Benefits Improvement and Protection Act 

CBA Controlled Before-After 

CCHT Coordination/Home Telehealth 

CI Confidence interval 

CINAHL® Cumulative Index to Nursing and Allied Health®

CMS Centers for Medicare and Medicaid Services 

CMSA Case Management Society of America 

DMAA Disease Management Association of America 

EPC Evidence-based Practice Center 

GHb Glycated hemoglobin 

GRACE Geriatric Resources for Assessment and Care of Elder 

HAPI Health and Psychological Index 

IOM Institute of Medicine 

ICU Intensive care unit 

ITS Interrupted Time Series 

JCAHO Joint Commission on Accreditation of Healthcare Organizations 

LOS Length of Stay 

LTC Long-term care 

MHSO Medicare Health Support Organizations 

MMA Medicare Prescription Drug, Improvement, and Modernization Act 

NCQA National Committee for Quality Assurance 

NQF National Quality Forum 

OR Odds ratio 
158

PACE Program of All-Inclusive Care for the Elderly 

RCT Randomized Controlled Trial 

ROI Return on Investment 

RR Risk ratio 

SGIM Society of General Internal Medicine 

S/HMO Social Health Maintenance Organization 

URAC Utilization Review Accreditation Commission 

VA Department of Veterans Affairs 
APPENDIXES: 

to 

“Closing the Quality Gap: A Critical Analysis of Quality 

Improvement Strategies, Volume 7—Care Coordination” 

Prepared by the Stanford University-UCSF 

Evidence-based Practice Center 

(Contract #290-02-0017) 
A-1 

Appendix A: Exact Search Strings 

Medline® Database Search 

#1: Targets articles addressing care coordination 

"Coordinated care" OR "care coordination" OR "collaborative care" OR "integrated care" OR 

"shared care" OR "transitional care" OR "comanagement" OR "case management" OR 

"synchronized care" OR "interdisciplinary care" OR "disease management" OR "Progressive 

Patient Care"[MeSH] OR "Continuity of Patient Care"[MeSH] OR "Patient-Centered 

Care"[MeSH] OR "Patient Care Planning"[MeSH] OR "Disease Management"[MeSH] OR 

"Delivery of Health Care, Integrated"[MeSH] OR (care AND (integrat* OR collaborat* OR 

coordinat* OR transition* OR interdisciplin* OR shared OR comanagement OR cooperat* OR 

aftercare OR interinstitution* OR synchron* OR harmon* OR manage*)) 

#2: Targets systematic reviews 

((meta-analysis [pt] OR meta-analysis [tw] OR metanalysis [tw]) OR ((review [pt] OR guideline 

[pt] OR consensus [ti] OR guideline* [ti] OR literature [ti] OR overview [ti] OR review [ti] OR 

Decision Support Techniques [mh]) AND ((Cochrane [tw] OR Medline [tw] OR CINAHL [tw] 

OR (National [tw] AND Library [tw])) OR (handsearch* [tw] OR search* [tw] OR searching 

[tw]) AND (hand [tw] OR manual [tw] OR electronic [tw] OR bibliographi* [tw] OR database* 

OR (Cochrane [tw] OR Medline [tw] OR CINAHL [tw] OR (National [tw] AND Library 

[tw]))))) OR ((synthesis [ti] OR overview [ti] OR review [ti] OR survey [ti]) AND (systematic 

[ti] OR critical [ti] OR methodologic [ti] OR quantitative [ti] OR qualitative [ti] OR literature [ti] 

OR evidence [ti] OR evidence-based [ti]))) BUTNOT (case report [mh] OR case* [ti] OR report 

[ti] OR editorial [pt] OR comment [pt] OR letter [pt]) 

#3: Targets systematic reviews addressing care coordination 

#1 and #2 

#4: Limits articles found through search #3 to humans and English Language 

#3 limited to English, Human 

Cumulative Index to Nursing and Allied Health (CINAHL®) Database 

Search 

NOTE: Searching the CINAHL® database required searching for different time frames as shown 

below. This search was updated to November 15, 2006. 

#1: Targets disease management specific articles (1982 to May Week 2, 2005) 

-------------------------------------------------------------------------------- 

1 "Continuity of Patient Care"/ or Case Management/ or care coordination.mp. (8222) 

2 *"Continuity of Patient Care"/ (999) 

3 exp *"Continuity of Patient Care"/ (1825) 

4 3 (1825) 

5 limit 4 to research (560) 
A-2

6 exp research/ or study design/ (300305) 

7 5 and 6 (526) 

8 ("coordinated care" or "uncoordinated care").mp. [mp=title, subject heading word, abstract, 

instrumentation] (120) 

9 ("discontinuity of care" or "transfer of responsibility" or "documentation of follow-up" or 

"documentation of followup").mp. [mp=title, subject heading word, abstract, instrumentation] 

(44) 

10 ("handoff" or "consults" or referral or "information transfer" or "telephone care" or "care 

coordination" or "discharge planning").mp. [mp=title, subject heading word, abstract, 

instrumentation] (11922) 

11 ("collaborative care" or "integrated care" or "shared care" or "transitional care" or 

"comanagement" or "synchronized care").mp. [mp=title, subject heading word, abstract, 

instrumentation] (1991) 

12 ("interdisciplinary care" or "disease management" or "case management").mp. [mp=title, 

subject heading word, abstract, instrumentation] (9912) 

13 case management/ or progressive patient care/ (6366) 

14 continuity of patient care/ (2086) 

15 case management/ or patient centered care/ (8850) 

16 Nursing Care Plans/ or patient care planning.mp. (2033) 

17 Health Care Delivery, Integrated/ (952) 

18 (care and (integrat$ or collaborat$ or coordinat$ or transition$ or interdisciplin$ or shared 

or comanagement or cooperat$ or aftercare or interinstitution$ or synchron$ or harmon$ or 

manage$)).mp. [mp=title, subject heading word, abstract, instrumentation] (60301) 

19 1 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 (76912) 

20 limit 19 to research (22658) 

21 1 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 (28054) 

22 limit 21 to research (8216) 

23 ("care coordination" or "coordinated care" or "uncoordinated care" or "discontinuity of 

care" or "transfer of responsibility" or "documentation of followup" or "documentation of 

follow-up").m_titl. (114) 

24 (handoff or referral or consults or "information transfer" or "telephone care" or 

"collaborative care" or "integrated care" or "shared care" or "transitional care" or "synchronized 

care" or comanagement or "interdisciplinary care").m_titl. (1203) 

25 ("discharge planning" or "case management" or "disease management").m_titl. (3528) 

26 *"Continuity of Patient Care"/ or *"Health Care Delivery, Integrated"/ or *"Case 

Management"/ or *"Progressive Patient Care"/ or *"Patient Centered Care"/ (7733) 

27 *"Nursing Care Plans"/ or *"Patient Care Planning"/ (560) 

28 23 or 24 or 26 (8901) 

29 limit 28 to research (1616) 

30 25 or 27 (4081) 

31 limit 30 to research (741) 

32 31 not 29 (383) 

33 from 32 keep 1-383 (383) 
A-3

#2: Targets case management specific articles (1982 to May Week 2, 2005) 

-------------------------------------------------------------------------------- 

1 "Continuity of Patient Care"/ or Case Management/ or care coordination.mp. (8222) 

2 *"Continuity of Patient Care"/ (999) 

3 exp *"Continuity of Patient Care"/ (1825) 

4 3 (1825) 

5 limit 4 to research (560) 

6 exp research/ or study design/ (300305) 

7 5 and 6 (526) 

8 ("coordinated care" or "uncoordinated care").mp. [mp=title, subject heading word, abstract, 

instrumentation] (120) 

9 ("discontinuity of care" or "transfer of responsibility" or "documentation of follow-up" or 

"documentation of followup").mp. [mp=title, subject heading word, abstract, instrumentation] 

(44) 

10 ("handoff" or "consults" or referral or "information transfer" or "telephone care" or "care 

coordination" or "discharge planning").mp. [mp=title, subject heading word, abstract, 

instrumentation] (11922) 

11 ("collaborative care" or "integrated care" or "shared care" or "transitional care" or 

"comanagement" or "synchronized care").mp. [mp=title, subject heading word, abstract, 

instrumentation] (1991) 

12 ("interdisciplinary care" or "disease management" or "case management").mp. [mp=title, 

subject heading word, abstract, instrumentation] (9912) 

13 case management/ or progressive patient care/ (6366) 

14 continuity of patient care/ (2086) 

15 case management/ or patient centered care/ (8850) 

16 Nursing Care Plans/ or patient care planning.mp. (2033) 

17 Health Care Delivery, Integrated/ (952) 

18 (care and (integrat$ or collaborat$ or coordinat$ or transition$ or interdisciplin$ or shared 

or comanagement or cooperat$ or aftercare or interinstitution$ or synchron$ or harmon$ or 

manage$)).mp. [mp=title, subject heading word, abstract, instrumentation] (60301) 

19 1 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 (76912) 

20 limit 19 to research (22658) 

21 1 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 (28054) 

22 limit 21 to research (8216) 

23 ("care coordination" or "coordinated care" or "uncoordinated care" or "discontinuity of 

care" or "transfer of responsibility" or "documentation of followup" or "documentation of 

follow-up").m_titl. (114) 

24 (handoff or referral or consults or "information transfer" or "telephone care" or 

"collaborative care" or "integrated care" or "shared care" or "transitional care" or "synchronized 

care" or comanagement or "interdisciplinary care").m_titl. (1203) 

25 ("discharge planning" or "case management" or "disease management").m_titl. (3528) 

26 *"Continuity of Patient Care"/ or *"Health Care Delivery, Integrated"/ or *"Case 

Management"/ or *"Progressive Patient Care"/ or *"Patient Centered Care"/ (7733) 

27 *"Nursing Care Plans"/ or *"Patient Care Planning"/ (560) 

28 23 or 24 or 26 (8901) 

29 limit 28 to research (1616) 
A-4

30 25 or 27 (4081) 

31 limit 30 to research (741) 

32 31 not 29 (383) 

33 from 32 keep 1-383 (383) 

34 29 and 31 (358) 

35 from 34 keep 1-358 (358) 

#3: Targets articles that have the term “care coord” in title/abstract (2003 to 2005) 

(NOTE: Searches 3, 4, 5 and 6 are the same except for the years searched) 

-------------------------------------------------------------------------------- 

1 "Continuity of Patient Care"/ or Case Management/ or care coordination.mp. (8222) 

2 *"Continuity of Patient Care"/ (999) 

3 exp *"Continuity of Patient Care"/ (1825) 

4 3 (1825) 

5 limit 4 to research (560) 

6 exp research/ or study design/ (300305) 

7 5 and 6 (526) 

8 ("coordinated care" or "uncoordinated care").mp. [mp=title, subject heading word, abstract, 

instrumentation] (120) 

9 ("discontinuity of care" or "transfer of responsibility" or "documentation of follow-up" or 

"documentation of followup").mp. [mp=title, subject heading word, abstract, instrumentation] 

(44) 

10 ("handoff" or "consults" or referral or "information transfer" or "telephone care" or "care 

coordination" or "discharge planning").mp. [mp=title, subject heading word, abstract, 

instrumentation] (11922) 

11 ("collaborative care" or "integrated care" or "shared care" or "transitional care" or 

"comanagement" or "synchronized care").mp. [mp=title, subject heading word, abstract, 

instrumentation] (1991) 

12 ("interdisciplinary care" or "disease management" or "case management").mp. [mp=title, 

subject heading word, abstract, instrumentation] (9912) 

13 case management/ or progressive patient care/ (6366) 

14 continuity of patient care/ (2086) 

15 case management/ or patient centered care/ (8850) 

16 Nursing Care Plans/ or patient care planning.mp. (2033) 

17 Health Care Delivery, Integrated/ (952) 

18 (care and (integrat$ or collaborat$ or coordinat$ or transition$ or interdisciplin$ or shared 

or comanagement or cooperat$ or aftercare or interinstitution$ or synchron$ or harmon$ or 

manage$)).mp. [mp=title, subject heading word, abstract, instrumentation] (60301) 

19 1 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 (76912) 

20 limit 19 to research (22658) 

21 1 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 (28054) 

22 limit 21 to research (8216) 

23 ("care coordination" or "coordinated care" or "uncoordinated care" or "discontinuity of 

care" or "transfer of responsibility" or "documentation of followup" or "documentation of 

follow-up").m_titl. (114) 
A-5

24 (handoff or referral or consults or "information transfer" or "telephone care" or 

"collaborative care" or "integrated care" or "shared care" or "transitional care" or "synchronized 

care" or comanagement or "interdisciplinary care").m_titl. (1203) 

25 ("discharge planning" or "case management" or "disease management").m_titl. (3528) 

26 *"Continuity of Patient Care"/ or *"Health Care Delivery, Integrated"/ or *"Case 

Management"/ or *"Progressive Patient Care"/ or *"Patient Centered Care"/ (7733) 

27 *"Nursing Care Plans"/ or *"Patient Care Planning"/ (560) 

28 23 or 24 or 26 (8901) 

29 limit 28 to research (1616) 

30 25 or 27 (4081) 

31 limit 30 to research (741) 

32 31 not 29 (383) 

33 from 32 keep 1-383 (383) 

34 29 and 31 (358) 

35 from 34 keep 1-358 (358) 

36 29 not (31 or 32) (1258) 

37 from 36 keep 1-1258 (1258) 

38 limit 37 to yr=2003 - 2005 (352) 

39 from 38 keep 1-352 (352) 

#4: Targets articles that have the term “care coord” in title/abstract (2000 to 2002) 

Search strategy used is same as #3. 

#5: Targets articles that have the term “care coord” in title/abstract (1995 to 1999) 

Search strategy used is same as #3. 

#6: Targets articles that have the term “care coord” in title/abstract (1966 to 1994) 

Search strategy used is same as #3. 

Cochrane Database of Systematic Reviews, American College of 

Physicians Journal Club, Database of Abstracts of Reviews of Effects 

(through November 15, 2006) 

1 "Continuity of Patient Care"/ or Case Management/ or care coordination.mp. (294) 

2 "Quality of Health Care"/ or Quality Improvement/ or improv$.mp. (63628) 

3 1 and 2 (118) 

4 from 3 keep 2,5-8,10 (6) 

5 from 3 keep 3-4,11-12,14,19,22,25-26,28,46,50-51,53,70 (15) 

6 care coordination.m_titl. (5) 

7 [from 6 keep 2-4,6-15,17-20,22-24,26-27,29-30] (0) 

8 5 or 7 (15) 

9 [from 8 keep 1-39] (0) 

10 from 8 keep 5,7-10,13-15 (8) 
A-6

PsychInfo Database Search 

Search updated to November 15, 2006 

1872 to May Week 5, 2005 

-------------------------------------------------------------------------------- 

1 "Continuity of Patient Care"/ or Case Management/ or care coordination.mp. (1573) 

2 ("coordinated care" or "uncoordinated care").mp. [mp=title, abstract, subject headings, table 

of contents, key concepts] (47) 

3 integrated care.mp. [mp=title, abstract, subject headings, table of contents, key concepts] 

(124) 

4 "Quality of Health Care"/ or Quality Improvement/ or improv$.mp. (113208) 

5 1 or 2 or 3 (1730) 

6 4 and 5 (282) 

7 from 6 keep 1-22 (22) 

8 from 6 keep 23-209 (187) 

9 exp meta analysis/ (2588) 

10 6 and 9 (0) 

11 5 and 9 (0) 

12 exp "literature review"/ (22105) 

13 5 and 9 (0) 

14 5 and review.mp. [mp=title, abstract, subject headings, table of contents, key concepts] 

(170) 

15 14 and systematic.mp. [mp=title, abstract, subject headings, table of contents, key 

concepts] (9) 

16 from 15 keep 2 (1) 

17 "systematic review".m_titl. (536) 

18 5 and 17 (1) 

19 exp integrated services/ (1061) 

20 case management/ or discharge planning/ (1622) 

21 19 or 20 or 5 (2826) 

22 21 and 17 (1) 

23 21 and (metanalysis or "meta analysis" or "systematic review").mp. [mp=title, abstract, 

subject headings, table of contents, key concepts] (7) 

24 from 23 keep 1-7 (7) 

Sociological Abstracts Database and Social Services Abstracts 

Database Search 

Through November 15, 2006 

-------------------------------------------------------------------------------- 

Systematic review and (coordinated care or continuous care or uncoordinated care or care 

planning) 
B-1

Appendix B: Sample Data Abstraction Forms 

Level One (Screening Title and Abstract) Form 

PLEASE NOTE: If you feel an article should be excluded, please answer the question on the 

basis of which you are excluding it. You do not need to answer the remaining questions. 

1. Does this article report a systematic review? 

F Yes 

F No 

F Can't tell 

F Did not check 

2. Does this article report on some component of care coordination? 

(Care coordination for the purposes of this triage can be defined as those activities in which two 

or more people are involved in coordination of care for a patient. Components to consider 

include disease management, case management, discharge planning, coordination between 

health care providers and/or organization units). 

NOTE: Please document why you consider this care coordination. If you exclude as not being 

care coordination, please specify why. 

 

F Yes, specify: ______________________________________________________________ 

F No, specify: _______________________________________________________________ 

F Exclude for review but keep as background, specify: ______________________________ 

F Can't tell 

F Did not check 

 

3. Does this article report results from studies that are conducted exclusively in an in-patient 

setting? 

F Yes 

F No 

F Can't tell 

F Did not check 
B-2

Level Two (Full Text) Abstraction Form 

1. Does this article merit full text review? (check ANY that apply) 

F Yes 

F No - not a systematic review 

F No - does not address care coordination: _________________________________ 

(Coordination of care can be broadly defined as the deliberate assembly, exchange, and 

integration of information by two or more participants involved in a patient’s care to 

facilitate appropriate delivery of health care services. For the purpose of the review, we 

restrict our definition of coordination of care to the deliberate assembly, exchange, and 

integration of information by two or more clinicians involved in a patient’s care to 

facilitate appropriate delivery of health care services.) 

F No - cost effectiveness study only 

F No - study conducted in an in-patient setting only 

F No - foreign language 

F No - other (specify): ________________________________ 

F Not sure - need to discuss: ____________________________ 

 

 2. Does this article meet inclusion criteria? (check ALL that apply) 

F Yes - multiple providers 

F Yes - complex patient 

F Yes - multiple settings 

F No - no intervention evaluated 

F No - self management only 

F No - other (not sure) 

3. Does the entire review focus on care coordination or does only a part of the review focus on 

care coordination? 

F Entire review is on care coordination 

F Only a part of the review is on care coordination (please remember to only abstract results 

for the care coordination part of the article) 

Quality Assessment of Review 

 

4. Does the study report a review/research question? (This might be stated under the purpose of 

the review) 

F Yes 

F No 

5. Are the inclusion/exclusion criteria used to select articles stated? (Determine if the criteria 

address study design, patient populations, interventions and outcomes of interest that determine 

inclusion/exclusion) 

F Yes 

F Not stated 
B-3

6. Were the studies examined independently to determine inclusion/exclusion of the study for the 

review (i.e., dual level 1 review)? 

F Yes 

F No 

F Not stated 

7. Was the data abstraction done by at least 2 independent reviewers? 

F Yes 

F No 

F Not stated 

8. Does the review report on how disagreements between reviewers were handled? 

F Yes 

F No 

F Not applicable - no multiple reviewers 

9. Did the research team include the following team members? (check ALL that apply). [To 

answer this question, look at the author affiliations, acknowledgements section and methods 

section] 

F Research librarian 

F Statistician 

F Methods expert 

F Topic expert 

F Not stated 

 

10. What study designs does the review include? (check ALL that apply) 

F Randomized controlled trials (RCT) 

F Quasi-RCT 

F Controlled before-after 

F Interrupted time series 

F Prospective studies 

F Cross-sectional studies 

F Other (specify): __________________________________________________________ 

F Not stated 

 

11. Which databases were searched by the review? (check ALL that apply) 

F Medline 

F EMBASE 

F Cochrane 

F PsychInfo 

F Social Sciences Register (or other social sciences database): _______________________ 

F Other (specify): ___________________________________________________________ 

F Article does not specify the databases searched 

 
B-4

12. Does the review provide details of the search strategy used? 

F Yes 

F No 

13. Does the review indicate the time frame covered by the search? 

F Yes (specify): ___________________________________________________________ 

F No 

 

14. Does the review provide sufficient detail on the search for articles to indicate that a 

substantial effort was made to obtain all relevant articles? 

F Yes, substantial effort made 

F No, substantial effort not made 

15. Does the review adequately address the validity of the included studies? (e.g., provides an 

explanation of the criteria used to assess the studies) 

F Yes 

F No 

F Not stated 

F Not applicable - no included studies 

16. Does the review provide sufficient details of the individual studies presented? (e.g., paper has 

a table listing the included studies, details on the study design, sample sizes, patient 

characteristics etc.) 

F Yes 

F No 

F Not applicable - no included studies 

17. Does the review summarize the primary studies included appropriately? (e.g., includes a 

narrative summary of results; may or may not include a quantitative analysis) 

F Yes 

F No 

F Unclear: _________________________________________________________________ 

F Not applicable - no included studies 

Systematic Review Details 

18. What topic does the review focus on? 

F Asthma 

F Cancer screening 

F Children with special health care needs 

F Congestive heart failure 

F Diabetes 

F Discharge planning 

F End of life associated with advanced organ system failure 

F Frailty associated with old age 

F Hypertension 

F Immunization 
B-5

F Ischemic heart disease 

F Major depression 

F Medication management 

F Other (specify): ____________________________________________________________ 

F No specific clinical focus 

 

19. How many studies were included in the final analysis? _____________________________ 

20. What populations does the review include? 

F General population 

F Children 

F Elderly 

F Other (specify): ____________________________________________________________ 

F Not stated 

F Not applicable - no included studes 

 

21. Does the review provide information on the setting of the included studies? (check ALL that 

apply) 

F Outpatient clinic 

F Specialist facility 

F Managed care setting (specify): ______________________________________________ 

F Home 

F Community setting (specify): ________________________________________________ 

F Other setting (specify): _____________________________________________________ 

F Not stated 

F Not applicable - no included studies 

 

22. Does the review provide a description of a conceptual framework used to inform the search 

strategy or data abstraction? 

(May include: operational definition of coordination; theories used to inform framework - e.g., 

behavioral change theories, organizational design theories; hypothesized mechanisms through 

which specific QI strategies act; categorization of QI approaches) (check ALL that apply) 

 

F Yes, operational definition of care coordination 

F Yes, theories explicitly applied (e.g.,organization theory, behavior change, structureprocess outcomes) 

F Yes, hypothesized mechanisms through which specific QI strategies act (e.g., improve 

information exchange patient-provider, improve information exchange provider-provider, 

improve information continuity) 

F Yes, categorization of QI approaches 

F No conceptual framework provided 

 
B-6

23. How were the results of the review presented? 

F Narrative results 

F Quantitative analysis (meta-analysis) 

F Combination of narrative results and quantitative analysis 

F No results 

Care Coordination Interventions 

24. What care coordination interventions were the authors looking for? (this will probably be 

found in the search strategy or inclusion/exclusion criteria. e.g.: disease management, 

multidisciplinary teams etc) 

F State intervention (s) (list all the interventions): ___________________________________ 

F Unclear 

F Not stated 

25. How did the authors classify the individual studies included in the review into the 

intervention groupings? For each intervention or term used to classify the studies, list the term 

used, its definition and the number of studies included for each intervention/term. 

 

Term Used Definition # of included studies 

Intervention/Term 1 

Intervention/Term 2 

Intervention/Term 3 

Intervention/Term 4 

Intervention/Term 5 

Intervention/Term 6 

Intervention/Term 7 

Intervention/Term 8 

Intervention/Term 9 

Intervention/Term 10 

 

26. What coordination-related measures are reported in the review (i.e., did systematic review 

report process measures regarding implementation, where coordination is an implied or explicit 

component of intervention)? 

F None reported, no discussion of implementation 

F No measures reported, implementation of coordination activities and barriers discussed 

qualitatively 

F Yes, process measures (e.g., frequency of follow up visits/referrals, rate of contacts among 

providers, rate of provider-patient contacts) 

F Yes, participant self-report re: potential predictors of behavioral change (e.g., motivational, 

action, and stage of change constructs) [NOTE: evaluation of behavior change constructs 

and development of questionnaires appear to be under development, so if present in studies, 

likely to be study-specific] 

F Yes, participant self-report re: coordination-related concepts (e.g., interprofessional 

collaboration, continuity of care) [NOTE: the table below includes some of the survey 

instruments that we’ve come across so far. Because most measures listed below were 
B-7

developed for the inpatient setting, it is unlikely that reviews will mention these unless 

modifications were made) 

 

The table below lists some survey instruments that include an explicit "coordination" domain 

and have undergone at least initial psychometric assessment (i.e., separate study of 

validity/reliability): 

Survey Instruments Reference 

Collaborative Practice Scales (CPS) Weiss 1985 

Collaboration and Satisfaction about Care Decisions (CSACD) Baggs 1994 

ICU Nurse-Physician Questionnaire Shortell 1991 

Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration Hojat 1999 

Long-term-care interdisciplinary team performance questionnaire 

(adapted from ICU-Nurse Physician Questionnaire) 

Temkin-Greener 2004 

Physician - Pharmacist Collaboration Instrument (PPCI) Zillich 2005 

Care Transitions Measure (CTM) Coleman 

27. What were the barriers, if any, to the usefulness of the review? (To answer this question, you 

will need to assess the usefulness of the review as well as see what the limitations were) 

Systematic Review Results 

28. What outcomes were measured by the review that relate to care coordination interventions? 

F Clinical outcomes (specify): __________________________________________________ 

F Health services utilization (specify): ___________________________________________ 

F Cost (specify): ____________________________________________________________ 

F Cost-effectiveness analysis: __________________________________________________ 

F Quality of life (specify): _____________________________________________________ 

F Other (specify): ____________________________________________________________ 

F Not stated: ________________________________________________________________ 
B-8

29. Please report the main findings of the review. 

(the goal here is to highlight the results that readers are likely to find interesting. Feel free to 

use text as used in the article, but if using it verbatim, please indicate this when abstracting the 

information). Listed below are some other things to include in this section, if provided in the 

article. 

Please provide 1-2 sentences of the overall findings of the review. Include here any information 

on negative or ineffective interventions as well. 

If the authors provide any kind of synthesis on lessons learned or any specific 

elements/components that contributed to the success or failure of the intervention, include that 

information. 

If any of the findings focus on more severe/complex patients, please note that as well. 

 

30. Is there material in this article that could be abstracted using the evaluation framework? 

F Yes 

F No 

(TO MAKE THIS DECISION, CONSIDER THE FOLLOWING: If the authors provide enough 

information and detail in the review on any of the following items, then this article should be 

included in the evaluation framework: 

o details on the original studies that offer insight about the mechanisms of coordination, 

e.g., how patient monitoring or population surveillance links with planning for care, 

which activities or processes were integrated better by the coordination intervention; 

o synthesis of the lessons learned or which components of the intervention were effective vs. 

ineffective in terms of any outcomes; 

o barriers to the success of the intervention(s); structural contexts that influenced care 

coordination, e.g., physical infrastructure (availability of decision support systems, 

proximity of those involved in coordinating care, etc), reinforcing characteristics 

(financial incentives, integration of funding); 

o details about characteristics of tasks or activities that were coordinated, e.g., task 

complexity, task uncertainty, level of interdependence among tasks, number of 

participants involved in coordinating activities)

 

31. Please specify any other comments or concerns. 
C-1 

Appendix C: List of Excluded Reviews 

Citation Reason for 

exclusion 

Best care for the dying is listening to their needs: individual needs should dictate care 

decisions. Patient-Focused Care and Satisfaction. 1998;6(4):44-6. 

Not a systematic 

review 

Case management of patients with chronic renal insufficiency did not improve outcomes 

over usual care. Research Activities. 1999;225:9. 

Not a systematic 

review 

Continuity of caregivers during pregnancy and childbirth. Pract Midwife. 1999;2(1):10-1. Not a systematic 

review 

Delegation and referral in primary healthcare teams. Nursing Standard. 1997;11(49):32-

3. 

Not a systematic 

review 

Hospital CM and managed care growth link questioned: 74% of acute care facilities have 

CM departments. Hospital Case Management. 1999; 7(8):138. 

Not a systematic 

review 

Medicare hospital discharge planning: report from the DHHS Office of the Inspector 

General. Continuum: An Interdisciplinary Journal on Continuity of Care. 1998;18(1):11-6. 

Not a systematic 

review 

Patient management benefits clients, agency, and hospital. Hospital Home Health. 

1992;9(4):52-4. 

Not a systematic 

review 

Pilot project: proactive protocol for diabetes: can CM make a difference in diabetes 

outcomes? Hospital Case Management. 2001;9(10):147-9. 

Not a systematic 

review 

Transitional care from hospital to home improves health of seniors while saving money. 

Nursingmatters. 1999;10(12):13. 

Not a systematic 

review 

Treatment outlines for the management of schizophrenia. The Quality Assurance 

Project. Aust N Z J Psychiatry. 1984;18(1):19-38. Not care coordination 

Abbott J, Young A, Haxton R, Van Dyke P. Collaborative care: a professional model that 

influences job satisfaction. Nursing Economics. 1994;12(3):167-9. 

Not a systematic 

review 

Abercrombie PD. Improving adherence to abnormal Pap smear follow-up. J Obstet 

Gynecol Neonatal Nurs. 2001;30(1):80-8. Not care coordination 

Abir F, Bell R. Assessment and management of the obese patient. Crit Care Med. 

2004;32(4 Suppl):S87-91. 

Not a systematic 

review 

Adair CE, McDougall GM, Beckie A, et al. History and measurement of continuity of care 

in mental health services and evidence of its role in outcomes. Psychiatric Services. 

2003;54(10):1351-6. 

Not care coordination 

Adatia FA, Damji KF. Chronic open-angle glaucoma. Review for primary care physicians. 

Can Fam Physician. 2005 Sep;51:1229-37. 

Not a systematic 

review 

Alberts MJ, Hademenos G, Latchaw RE, et al. Recommendations for the establishment 

of primary stroke centers. Brain Attack Coalition. JAMA. 2000;283(23):3102-9. Not care coordination 

Alexander DA, Klein S. Biochemical terrorism: too awful to contemplate, too serious to 

ignore: subjective literature review. Br J Psychiatry. 2003;183:491-7. 

Not a systematic 

review 
C-2

Allen D, Lyne P, Griffiths L. Fraying seams... the divisions between health and social 

services should be invisible to those who use them... a version of this article appeared in 

Nursing Times. Therapy Weekly. 2001;28(22):4. 

Not available 

Allred CA, Arford PH, Michel Y, Veitch JS, Dring R, Carter V. Case management: the 

relationship between structure & environment. Nursing Economics. 1995;13(1):32-41. 

Not a systematic 

review 

Amruso NA, O'Neal ML. Pharmacist and physician collaboration in the patient's home. 

Ann Pharmacother. 2004;38(6):1048-52. 

Not a systematic 

review 

Anderson JL. Nursing management of the cancer patient in pain: a review of the 

literature. Cancer Nurs. 1982;5(1):33-41. Not care coordination 

Anderson MA, Helms LB. Quality improvement in discharge planning: an evaluation of 

factors in communication between health care providers. Journal of Nursing Care 

Quality. 1994;8(2):62-72. 

Not a systematic 

review 

Anderson MA, Tredway C. Focus on research. Care manager communication in home 

health care referrals. Chart. 1998;95(1):5. 

Not a systematic 

review 

Andlin-Sobocki P. Economic evidence in addiction: a review. Eur J Health Econ. 2004;5 

Suppl 1:S5-12. Not care coordination 

Armitage SK, Kavanagh KM. The discharge liaison nurse at the interface of hospital and 

community nursing services. International Journal of Nursing Practice. 1996;2(4):215-21. 

Not a systematic 

review 

Aronson N, Lefevre F, Piper M, et al. Management of chronic asthma. Evid Rep Technol 

Assess (Summ). 2001;(44):1-10. Not care coordination 

Bachrach LL. Young adult chronic patients: an analytical review of the literature. Hosp 

Community Psychiatry. 1982;33(3):189-97. 

Not a systematic 

review 

Balas EA, Krishna S, Kretschmer RA, Cheek TR, Lobach DF, Boren SA. Computerized 

knowledge management in diabetes care. Med Care. 2004;42(6):610-21. Not care coordination 

Barlow JH, Ellard DR. Psycho-educational interventions for children with chronic 

disease, parents and siblings: an overview of the research evidence base. Child Care 

Health Dev. 2004;30(6):637-45. 

Not care coordination 

Barr H, Hammick M, Koppel I, Reeves S. Systematic review of the effectiveness of 

interprofessional education: towards transatlantic collaboration. J Allied Health. 

1999;28(2):104-8. 

Not a systematic 

review 

Bauer M, Nay R. Family and staff partnerships in long-term care. A review of the 

literature. J Gerontol Nurs. 2003;29(10):46-53. 

Not a systematic 

review 

Baxter E. Patients, caregivers, and managing care. Geriatrics. 1997;52(2):S48-9. Not a systematic 

review 

Bayley EW, Carrougher GJ, Marvin JA, Knighton J, Rutan RL, Weber BF. Research 

priorities for burn nursing: rehabilitation, discharge planning, and follow-up care. Journal 

of Burn Care & Rehabilitation. 1992;13(4):471-6. 

Not a systematic 

review 

Bazzoli GJ, Dynan L, Burns LR, Yap C. Two decades of organizational change in health 

care: what have we learned? Med Care Res Rev. 2004;61(3):247-331. Not care coordination 
C-3

Beaudin CL, Lammers JC, Pedroja AT. Patient perceptions of coordinated care: the 

importance of organized communication in hospitals. Journal for Healthcare Quality. 

1999;21(5):18-23. 

Not a systematic 

review 

Beavis D, Simpson S, Graham I. A literature review of dementia care mapping: 

methodological considerations and efficacy. J Psychiatr Ment Health Nurs. 

2002;9(6):725-36. 

Not care coordination 

Bechel DL, Myers WA, Smith DG. Does patient-centered care pay off? Joint Commission 

Journal on Quality Improvement. 2000;26(7):400-9. 

Not a systematic 

review 

Bell R. Continuity of care: were we providing continuity of care for our clients? 

Perspectives. 1996;20(4):17-20. 

Not a systematic 

review 

Berk M, Berk L, Castle D. A collaborative approach to the treatment alliance in bipolar 

disorder. Bipolar Disord. 2004;6(6):504-18. Not care coordination 

Bernard-Bonnin AC, Stachenko S, Bonin D, Charette C, Rousseau E. Self-management 

teaching programs and morbidity of pediatric asthma: a meta-analysis. J Allergy Clin 

Immunol. 1995;95(1 Pt 1):34-41. 

Not care coordination 

Betz CL. Transition of adolescents with special health care needs: review and analysis of 

the literature. Issues in Comprehensive Pediatric Nursing. 2004;27(3):179-241. Not care coordination 

Bhui K, Stansfeld S, Hull S, Priebe S, Mole F, Feder G. Ethnic variations in pathways to 

and use of specialist mental health services in the UK. Systematic review. Br J 

Psychiatry. 2003;182:105-16. 

Not care coordination 

Bhutta ZA, Darmstadt GL, Hasan BS, Haws RA. Community-based interventions for 

improving perinatal and neonatal health outcomes in developing countries: a review of 

the evidence. Pediatrics. 2005 Feb;115(2 Suppl):519-617. 

Not care coordination 

Birthistle K, Carrington D. Fetal varicella syndrome--a reappraisal of the literature. A 

review prepared for the UK Advisory Group on Chickenpox on behalf of the British 

Society for the Study of Infection. J Infect. 1998;36 Suppl 1:25-9. 

Not care coordination 

Blaiss MS. Asthma disease management: a critical analysis. Ann Allergy Asthma 

Immunol. 2005 Nov;95(5 Suppl 1):S10-6 

Not a systematic 

review 

Blenkinsopp A, Anderson C, Armstrong M. Systematic review of the effectiveness of 

community pharmacy-based interventions to reduce risk behaviours and risk factors for 

coronary heart disease. J Public Health Med. 2003;25(2):144-53. 

Not care coordination 

Bloemen-Vrencken JH, de Witte LP, Post MW. Follow-up care for persons with spinal 

cord injury living in the community: a systematic review of interventions and their 

evaluation. Spinal Cord. 2005 Aug;43(8):462-75. 

Not an evaluation of 

an intervention 

Blondel B, Breart G. Home visits for pregnancy complications and management of 

antenatal care: an overview of three randomized controlled trials. Br J Obstet Gynaecol. 

1992;99(4):283-6. 

Not a systematic 

review 

Boockvar K, Fishman E, Kyriacou CK, Monias A, Gavi S, Cortes T. Adverse events due 

to discontinuations in drug use and dose changes in patients transferred between acute 

and long-term care facilities. Archives of Internal Medicine. 2004;164(5):545-50. 

Not a systematic 

review 
C-4

Bower P, Sibbald B. Systematic review of the effect of on-site mental health 

professionals on the clinical behaviour of general practitioners. BMJ. 

2000;320(7235):614-7. 

Duplicate publication 

Bower P. Primary care mental health workers: models of working and evidence of 

effectiveness. Br J Gen Pract. 2002;52(484):926-33. 

Not a systematic 

review 

Bowlyow JE. Acute and long-term care linkages: a literature review. Med Care Rev. 

1990;47(1):75-103. 

Not a systematic 

review 

Bradley P, Lindsay B. Epilepsy clinics versus general neurology or medical clinics. 

Cochrane Database Syst Rev. 2001(1):CD001910. Not care coordination 

Bradley P, Lindsay B. Specialist epilepsy nurses for treating epilepsy. Cochrane 

Database Syst Rev. 2001(4):CD001907. Not care coordination 

Brickman R, Axelrod R, Roberson D, Flanagan C. Clinical process improvement as a 

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C-5

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C-7

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C-10

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C-11

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C-12

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C-13

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an in-patient setting 

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Not a systematic 

review 

Mannino FV, Shore MF. Consultation research in mental health and related fields; a 

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review 

Mark H, Mark T. Health service applications. Parental reasons for non-response 

following a referral in school vision screening. Journal of School Health. 1999;69(1):35-8. 

Not a systematic 

review 

Markey BT, Igou JF. Medication discharge planning for the elderly. Patient Education 

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Not a systematic 

review 

Marsh MA. Discharge planning. Prairie Rose. 1992;61(2):9. Not a systematic 

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Not care coordination 

Martire LM, Lustig AP, Schulz R, Miller GE, Helgeson VS. Title Is It Beneficial to Involve 

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McAdam M, Wright N. A review of the literature considering the role of mental health 

nurses in assertive outreach. J Psychiatr Ment Health Nurs. 2005 Dec;12(6):648-60. Not care coordination 

McAlister FA, Lawson FM, Teo KK, Armstrong PW. A systematic review of randomized 

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C-14

McBride W, Ferrario C, Lyle PA. Hypertension and medical informatics. J Natl Med 

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McCloskey JC. The nursing care plan: past, present, and uncertain future - a review of 

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Not a systematic 

review 

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Not a systematic 

review 

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review 

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Not a systematic 

review 

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review 

Middleton J. The effect of case management on glycemic control in patients with type 2 

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review 

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Not a systematic 

review 

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No intervention 

evaluated 

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Not a systematic 

review 

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Not care coordination 
C-15

Monninkhof EM, van der Valk PD, van der Palen J, et al. Self-management education for 

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Not care coordination 

Montori VM, Smith SA. Information systems in diabetes: in search of the holy grail in the 

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review 

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Not a systematic 

review 

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No intervention 

evaluated 

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review 

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Norris SL, Nichols PJ, Caspersen CJ, et al. Increasing diabetes self-management 

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review 

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C-16

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Not a systematic 

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Palmer E, Mayers SP, Jr. Discharge planning effect on length of hospital stay. Archives 

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Not care coordination 

Parker M, Quinn J, Viehl M, et al. Issues in rural case management. Family & 

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Not a systematic 

review 

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review 

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Pelletier KR. A review and analysis of the clinical- and cost-effectiveness studies of 

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Pelletier KR. Clinical and cost outcomes of multifactorial, cardiovascular risk 

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Pengel HM, Maher CG, Refshauge KM. Systematic review of conservative interventions 

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Persily CA. Lay home visiting may improve pregnancy outcomes. Holist Nurs Pract. 

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No intervention 

evaluated 

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Proctor EK, Morrow-Howell N. Complications in discharge planning with Medicare 

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C-17

Rat AC, Henegariu V, Boissier MC. Do primary care physicians have a place in the 

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Reeves S, Meyer J, Glynn M, Bridges J. Coordination of interprofessional health care 

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Duplicate publication 

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Rosen M, Lindqvist R, Stenbeck M. Revise the review process of the Cochrane 

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review 

Rosen M. Behavioural techniques for the management of the child patient. A review of 

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review 

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Ruddy G, Rhee K. Transdisciplinary teams in primary care for the underserved: a 

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review 

Rushton J, Bruckman D, Kelleher K. Primary care referral of children with psychosocial 

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Ryan MJ, Jr., Gibson J, Simmons P, Stanek E. Effectiveness of aggressive management 

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C-18

Salazar MK. Maximizing the effectiveness of case management service delivery. Case 

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Schaefer AL, Anderson JA, Simms LM. Are they ready? Discharge planning for older 

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review 

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Schlemmer B. The status of discharge planning in intensive care units. Nursing 

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Schlenger WE, Kroutil LA, Roland EJ. Case management as a mechanism for linking 

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Schotland HM, Georeno AM, Pack AI. Obstructive sleep apnea: feasibility of a disease 

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review 

Schull DE, Tosch P, Wood M. Clinical nurse specialists as collaborative care managers. 

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Sempowski IP, Brison RJ. Dealing with office emergencies. Stepwise approach for family 

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Senlet P, Cagatay L, Ergin J, Mathis J. Bridging the gap: integrating family planning with 

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review 
C-19

Seth CM, White R. Research to practice. No place like home. Children's Voice. 

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Not a systematic 

review 

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Sherlock-Storey M, Milne D. What makes a good care manager? An analysis of care 

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Study conducted in 

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Skilbeck J, Payne S. Emotional support and the role of Clinical Nurse Specialists in 

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C-20

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Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ. Comprehensive geriatric 

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Duplicate publication 

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C-21

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No intervention 

evaluated 

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Not an evaluation of 

an intervention 

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review 

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Not a systematic 

review 

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Duplicate publication 

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Not care coordination 

Waters E. Evidence-based paediatric practice and its relation to the Cochrane 

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Not a systematic 

review 

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Not a systematic 

review 
C-22

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Not a systematic 

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No intervention 

evaluated 

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Not care coordination 

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Not care coordination 

Williams AJ, Baird SE. Literature review to establish nursing diagnosis cues for 

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review 

Wood D, Schuster M, Donald-Sherbourne C, Duan N, Mazel R, Halfon N. Reducing 

missed opportunities to vaccinate during child health visits: how effective are parent 

education and case management? Archives of Pediatrics & Adolescent Medicine. 

1998;152(3):238-43. 

Not a systematic 

review 
C-23

Woodcock AJ, Kinmonth A, Campbell MJ, Griffin SJ, Spiegal NM. Diabetes care from 

diagnosis: effects of training in patient-centred care on beliefs, attitudes and behaviour of 

primary care professionals. Patient Education and Counseling. 1999;37(1):65-79. 

Not a systematic 

review 

Woods P, Richards D. Effectiveness of nursing interventions in people with personality 

disorders. J Adv Nurs. 2003;44(2):154-72. Not care coordination 

Wool MS, Guadagnoli E, Thomas M, Mor V. Negotiating concrete needs: short-term 

training for high-risk cancer patients. Health and Social Work. 1989;14(3):184-95. 

Not a systematic 

review 

Wright C, Catty J, Watt H, Burns T. A systematic review of home treatment services--

classification and sustainability. Soc Psychiatry Psychiatr Epidemiol. 2004;39(10):789-

96. 

Not care coordination 

Yeo M, Sawyer SM. Strategies to promote better outcomes in young people with chronic 

illnesses. Ann Acad Med Singapore. 2003;32(1):36-42. 

Not a systematic 

review 

Youde J, Ruse C, Parker S, Fotherby M. A high diagnostic rate in older patients 

attending an integrated syncope clinic. Journal of the American Geriatrics Society. 

2000;48(7):783-7. 

Not a systematic 

review 

Young S. Case management and telehealth: outcomes and throughput. Lippincott's 

Case Management. 2004;9(6):300-2. 

Not a systematic 

review 
D-1

Appendix D: Technical Expert Panel and 

Peer Reviewers 

Technical Expert Panel 

Jeremy Grimshaw, M.B.Ch.B., Ph.D., F.R.C.G.P., University of Ottawa, Cochrane Collaboration 

Effective Practice and Organisation of Care Group (EPOC) 

Andrew Oxman, M.Sc., M.D., Department of Health Services Research, Norwegian Directorate 

for Health and Social Welfare, EPOC 

Russell Glasgow, Ph.D., Kaiser Permanente, Colorado 

Martin Eccles, M.D., F.Med.Sci., F.R.C.P., F.R.C.G.P., M.F.P.H.M., Centre for Health Services 

Research, University of Newcastle upon Tyne, EPOC 

Harmon Jordan, Sc.D., previously with New England Medical Center Evidence-based Practice 

Center, currently at ABT Associates 

Val Lawrence, M.D., The University of Texas Health Science Center at San Antonio and South 

Texas Veterans Health Care System 

James L. Zazzali, Ph.D., M.P.H., RAND Corporation 

Charles Homer, M.D., M.P.H., National Institute for Children’s Health Care Quality 

Peer Reviewers 

David Atkins, M.D., M.P.H., Chief Medical Officer, Agency for Healthcare Research and 

Quality, Center for Outcomes and Evidence 

Caroline Blaum, M.D., M.S., Associate Professor of Internal Medicine, Division of Geriatric 

Medicine, University of Michigan Research Scientist, Ann Arbor DVAMC GRECC 

Geriatrics Center 

Beth Branthaver, M.S., M.H.A., Manager, Quality and Performance Improvement, Care 

Management Institute, Kaiser Permanente 

Neale R. Chumbler, Ph.D., VA HSR&D/RR&D Rehabilitation Outcomes Research Center, 

NF/SG Veterans Health System, VA Stroke QUERI, & Assistant Professor, Department 

of Health Services Research, Management and Policy, University of Florida. 

Adams Darkins, M.D., M.P.H.M., Chief Consultant for Care Coordination, Veterans Health 

Administration 

Liza Greenberg, Consultant, Case Management Society of America 

Halsted R Holman, M.D., Professor of Medicine, Emeritus, Department of Medicine, 

Immunology and Rheumatology and Center for Clinical Immunology, Stanford 

University 

Denise Myers, R.N., M.P.H., Kaiser Permanente, Oakland, CA 

Deborah Peikes, Ph.D., M.P.A., Mathematica Policy Inc., Princeton, New Jersey 

John Santa, M.D., Assistant Director for Health Projects, Center for Evidence-based Policy, 

 Oregon Health and Sciences University 

Vincenza Snow, M.D., F.A.C.P., Senior Medical Associate, Scientific Policy, American College 

of Physicians 

Reva Winkler, M.D., M.P.H., Clinical Consultant, National Quality Forum, Washington, DC 

Merrick Zwarenstein, M.B., B.Ch., M.Sc., Principal Investigator, Knowledge Translation 

Program, Continuing Education, University of Toronto, Senior Scientist, Institute for 

Clinical Evaluative Sciences