Developing an Effective Care Coordination Model that Can Be Utilized for Multiple Patient Populations across a Large Provider Network.

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M. Cooper, Jefferson College of Population Health, Thomas Jefferson University, Philadelphia PA.


Care coordination programs have been used to close care gaps and improve patient outcomes. The goals of these programs are to increase the quality of patient care and develop collaborative multi-disciplinary teams that work on behalf of the patient. Organizations throughout the world have identified the importance of care coordination and its necessity for overall patient health. To be effective, care coordination models must fit the culture of the healthcare system in which they are implemented.

A large multi-site physician services organization that manages hundreds of practice and thousands of providers acknowledged the need to identify gaps in patients’ care. The organization identified the patient populations that were most impacted by gaps in care. The four populations identified were patients with diabetes, patients with hypertension, patients overdue for colorectal cancer screening and patients overdue for mammography screening. The tool to track those care gaps was implemented and monitored in primary care practice over a series of months.

Concurrently the organization acknowledged the need to build a comprehensive care coordination model that could align a patient’s care to improve outcomes. Two markets within the organization that were utilizing the care gap tool were recognized based on their high-risk patient population and because they had employed a care coordinator to manage their patient population.

The tool was evaluated and interviews were conducted with stakeholders in the select markets. The data from the tool was analyzed and improvements in care gaps were recognized for practices that utilized the tool. Opportunities for the tool and the care coordination program were identified through that analysis and through the interview process.

Following the analysis recommendations were made for what was needed to build a comprehensive care model to fit the culture of the organization. The long term goal is to create an integrated delivery system across different lines of business within the organization.

Presentation: 55:28

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