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Original Research

Improving Care Coordination in Primary Care

Wagner, Edward H. MD, MPH*; Sandhu, Nirmala MPH; Coleman, Katie MSPH*; Phillips, Kathryn E. MPH; Sugarman, Jonathan R. MD, MPH

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doi: 10.1097/MLR.0000000000000197
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Coordinating care for their patients has long been viewed as a core responsibility and defining characteristic of primary care.1 Today, a variety of conditions make it more difficult for a primary care practice to coordinate care. Many primary care providers spend little time in hospitals and insurance networks complicate consultant choice.2 Multiple electronic medical records complicate communication between providers and the transmission of patient information.3 As a consequence, surveys confirm that many specialists and PCPs report that they are not getting the information they need from other physicians or hospitals to provide high-quality care.3–6 Patients are often aware of7 and disturbed by these care coordination failures.8,9

Care coordination is also a core component of all definitions of patient-centered medical homes, and was a major transformation focus in the Safety Net Medical Home Initiative (SNMHI). McDonald et al10 defined care coordination as “the deliberate organization of patient care activities between 2 or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services.” The focus of this paper is ensuring coordination of care for every patient whose care involves multiple providers or institutions.

But what can a PCMH do to improve its coordination of care? There is very little evidence to guide practice change. To address this problem, in a related study we tried to identify best practices in care coordination through literature review, and interviews with experts in care coordination and leaders of organizations that were innovating to improve care coordination.11 We summarized our findings in a Care Coordination Model (Fig. 1), which served as the organizing framework for the improvement of care coordination in the SNMHI.

Care Coordination Model.

In this paper, we evaluated whether application of the elements of the Care Coordination Model by SNMHI sites, as measured by the Key Activities Checklist (KAC), was associated with more effective care coordination as measured by another instrument, the PCMH-A.12


Development of the Care Coordination Model

With support from the Commonwealth Fund, we sought to identify evidence-based practices and possible best practice organizations in care coordination from literature review and interviews with national experts. We searched both the peer-reviewed and gray literature with search strategies built around the MESH headings—Continuity of Patient Care/organization & administration and Referral and Consultation as there is no MESH heading for care coordination. We interviewed 21 national experts in care coordination and primary care transformation. Through the literature review and interviews, we identified 20 practices or programs of interest. Using a semistructured interview guide, we interviewed a leader(s) or evaluator of each program who could provide a detailed description of program activities. The overall goal of the data collection was to create an implementation guide that would help care delivery organizations, especially primary care clinics, improve their ability to coordinate care for their patients when referred to specialists or community service agencies or when hospitalized or seen in the Emergency Department (ED).

From the interview transcripts and literature, we tried to identify the goals and common features of successful interventions and programs that targeted care coordination. The goal of care coordination is to consistently ensure high-quality referrals and transitions for patients that meet the 6 Institute of Medicine aims for high-quality health care,13 and ensure that all involved providers, institutions, and patients have the information and resources they need to optimize a patient’s care. Organizations that were successfully coordinating care, whether primary care, specialty organizations, or integrated systems, consistently exhibited the following characteristics:

(1) They assume accountability for coordinating their patients’ care: coordinating care requires deliberate action on the part of a PCMH to ensure the quality and safety of their patients’ referrals and transitions. These include efforts to identify key partner providers and organizations in their patients’ care, and tracking patients as they navigate to their next destination.

(2) They reach out to key care partners to build relationships and agreements so that they understand each others’ expectations and preferences: a clear and shared understanding of the roles, responsibilities, and expectations of all parties involved in the care of a patient is vital—especially in this era when many referrals and transitions involve providers who are strangers to each other. Our best-practice organizations tended to initiate conversations with providers and institutions used frequently by the practice and providers, and valued by both groups in an effort to build relationships, try to understand each other’s practice style and preferences, and reach agreement. An increasing number of practices are finding it useful to write down what has been agreed to in a compact or contract.14

(3) They support their patients when they go elsewhere for care: organizations that coordinate care well track referrals and transitions so that they can detect and address problems in information transfer, the appointment process, or the many other things that can go wrong when patients cross boundaries. These organizations provide support to referred or discharged patients experiencing problems. Such help may be rendered by a health professional as part of comprehensive care management or by a clerk for logistical or appointment issues.

(4) They establish connectivity for transmitting standardized information and communicating with care partners: successful care coordination includes the timely transfer of relevant information. Providers missing crucial patient information when needed account for many of the problems associated with referrals or transitions. Connectivity may be established through a shared electronic medical record, a web-based e-referral system,15 or agreements to use standardized referral request forms and consultation notes.

We attempted to illustrate what we learned in a Care Coordination Model (Fig. 1). The model includes the major providers and organizations involved in coordinating care—primary care practices, medical specialists, community service agencies, and hospital and emergency facilities—and summarizes the elements that are routinely addressed in successful care coordination interventions. The Care Coordination Model is described in greater detail in the SNMHI Care Coordination Implementation Guide.11


The SNMHI was a 5-year (2008–2013) Commonwealth Fund-sponsored project designed to develop and test a replicable model for supporting acceleration of PCMH transformation among 65 safety-net practices in 5 states. Practices included Federally Funded Community Health Centers (FQHCs), Rural Health Clinics, and other safety-net providers. Each practice received practice facilitation support from a practice coach and participated in state and national learning communities.16 The PCMH model developed for the project included 8 change concepts one of which was Care Coordination.17 Each change concept was further defined by 3–5 more specific changes. The specific changes under Care Coordination include:

  • Link patients with community resources to facilitate referrals and respond to social service needs.
  • Integrate behavioral health and specialty care into care delivery through colocation or referral agreements.
  • Track and support patients when they obtain services outside the practice.
  • Follow-up with patients within a few days of an emergency room visit or hospital discharge.
  • Communicate test results and care plans to patients/families.

We did not consider the final specific change—communicating test results to patients—in this study because it does not relate to services outside of the practice.


The analysis examines the correlations between the results of 2 practice self-assessment instruments—the PCMH-A and the KAC—completed periodically by SNMHI practices. The PCMH-A was developed by SNMHI faculty, including those who worked on the Care Coordination Model, and was based largely on the evidence supporting the development of the 8 change concepts.17 It measures progress along continua that reflect different aspects of care coordination—for example, referrals to specialty care, transitions from the ED or hospital, or linkages with community resources. The KAC was developed by the SNMHI’s practice facilitators based on the Care Coordination Model and supporting literature, and their coaching experience. It measures the extent which the practice took concrete actions in their efforts to improve care coordination—for example, develop an internal tracking system, identify patients seen in the ED, or discharged from the hospital.

Dependent Variables

The PCMH-A is a practice self-assessment instrument completed by staff in each clinic.11 It assesses the practice’s progress toward making the changes described by the 8 change concepts and 33 specific changes discussed above. For each specific change, the instrument asks staff to locate their practice on a continuum that includes 4 text descriptions representing levels of implementation of the change from little or none to full implementation, and a numeric scale ranging from 1 to 12. For this study, we focused on 5 PCMH-A items that relate to coordinating care with specialists, hospitals and EDs, and community service agencies. The 5 items are shown in Figure 2. Full implementation of these 5 items means that important medical, behavioral, and social services are accessible from preferred providers and agencies, and relationships with those providers ensure timely and effective patient care. The thinking that led to the Care Coordination Model probably influenced PCMH-A development, but not the specific construction of items as with the KAC. The 65 SNMHI practices completed the PCMH-A first in March, 2010 and every 6 months thereafter until March 2013. For the analyses in this paper, the dependent variables were the final (March 2013) scores for each of the 5 care coordination items.

Selected PCMH-A items for analysis.

Independent Variables

The change concepts and specific changes that guided the SNMHI are general statements that can be implemented using a variety of different approaches. To help with the implementation of changes, the SNMHI practice facilitators, working with the clinic staff, identified a group of specific activities based on the Care Coordination Model, the literature,18 and their coaching experience that help practices implement these changes. The activities were related to each change concept and specific change and organized in an instrument called the KAC. For this analysis, we included all care coordination key activities in the KAC related to referrals to specialists and community services, or transitions from hospital or ED. Table 1 lists the 12 care coordination key activities considered in this study along with a representative concrete example.

Key Activities for Care Coordination

For this paper, we organized the activities in accord with the 4 elements in the Care Coordination Model. For each key activity, the KAC asked practice teams to report the extent of their testing or implementation on the following scale: not planning to implement (0), planning to test or implement (1), testing or implementing (2), and completed implementation and maintaining (3). Practice teams completed the KAC on 4 occasions from April 2011 to October, 2012. For the analyses, we collapsed these 4 categories into a continuous variable that ranged from 0 to 1 that assesses the extent of implementation of each key activity as the proportion of assessments over time that scored a 2 or 3. For example, a score of 0.5 means that the clinic was implementing or sustaining the activity at 2 of the 4 time points.


We used Pearson Product Moment correlations to assess the strength of the relationship between the extent of implementation of each Key Activity with each of the 5 PCMH-A care coordination item final scores. The correlations provide some information as to the utility and validity of the Care Coordination Model as the key activities correspond to the 4 elements of the model. We postulated that practices that coordinate care well as measured by the PCMH-A would be more likely to: assume accountability for ensuring high-quality referrals and transitions, build relationships with key partners, track and support patients through the referral or transition process, and effectively share information.


Sixty-one SNMHI sites completed a final PCMH-A and are included in the analysis. Final PCMH-A item score means ranged from 8.6 to 10.5 on a scale of 1–12 (data not shown). In comparison with the mean scores at baseline, all final mean item scores were approximately 1 point higher (range, 0.8–1.5). On average, all of the key activities were being implemented and/or sustained on the majority of occasions on which they were being measured. As a result, the mean proportion of occasions on which key activities were being tested, implemented, or sustained ranged from 0.58 to 0.89. Relatively few practices failed to test or implement a key activity on any occasion.

The 60 correlations between each key activity and each PCMH-A item final score are shown in Table 2. Only 7 of the 60 were significantly positive at the P<0.05 level, and several were negative. Neither PCMH-A item 30 nor 34, which address the availability of specialty services and linkage with community agencies respectively, had any correlations with P<0.10. Conversely, 5 KAC activities were significantly correlated with PCMH-A item 33, which relates to following up patients seen in the ED or hospital. We arrayed the key activities in accord with the 4 elements of the Care Coordination Model. Key activities involving all 4 elements of the model were significantly correlated with at least one of the PCMH-A items. Activities related to accountability—identifying patients seen in the ED or hospital and examining ED visit patterns—not surprisingly correlated significantly with PCMH-A item 33. KAC item KA1—assuming accountability for improving care coordination—was correlated positively but not significantly with PCMH-A items assessing the ability to obtain high quality referrals and to follow-up ED and hospital patients, respectively. Key activities related to developing relationships with key partners were significantly correlated with having available behavioral health services and obtaining needed referrals. Two of the 3 activities linked to patient support were significantly correlated with better follow-up of patients seen in the ED or hospital. One key activity dealt with connectivity—develop and implement an information transfer system. It too was significantly correlated with better transitions from ED and hospital.

Correlations of Key Activities With PCMH-A Care Coordination Item Final Scores (n=61)

Not surprisingly, as some PCMH-A items and key activities relate to specific topics such as behavioral health or emergency room follow-up, correlations were strongest when the PCMH-A item and key activity addressed the same specific coordination issue; for example, behavioral health or ED follow-up.


The Care Coordination Model was based principally on what “best-practice” organizations were doing rather than on randomized trial evidence. Therefore, it is important to see whether putting the principles of the model into practice actually improves care coordination. The SNMHI provided such an opportunity because the Care Coordination Model strongly influenced the KAC as well as the resources and coaching efforts to help the 65 practices improve care coordination. Most of the key activities directed at improving care coordination in the KAC can be linked directly to the 4 elements of the Care Coordination Model as shown in Table 1.

We expected the key activities and PCMH-A items relating to the same specific change to be correlated, such as identifying patients seen in the ED and hospital and improving follow-up after an ED visit or hospitalization. Items in both instruments were influenced by the Care Coordination Model and its 4 elements or action areas. Assuming accountability for care coordination was positively, but not significantly, associated with progress in obtaining useful referrals and following up with patients seen in the ED. This provides some confirmation for the model’s recommendation that primary care practices seize the initiative if they want their patients’ care to be coordinated. Tracking referrals and patients in the hospital or ED would appear to be a logical early step, but the key activity—developing an internal tracking system—was not positively correlated with any PCMH-A item. However, identifying patients seen in the ED or discharged from hospital was correlated with more effective follow-up.

Another important early step in improving care coordination is to initiate conversations with key specialists, hospitals, and community agencies. If the conversations lead to stable relationships based on shared expectations and mutual trust, our analysis suggests that they contribute significantly to better care coordination. Developing and maintaining relationships with key partners in care and improving collaboration were strongly correlated with obtaining needed referrals and having integrated behavioral health services, respectively. Among SNMHI participants, developing relationships and building collaboration appear to be more critical than developing formal agreements as demonstrated by the lack of any significantly positive correlations with either KA6 or PCMH-A item 30. The lack of any positive correlations with PCMH-A item 30 (agreements with specialists) likely reflects the difficulties that many safety-net practices experience in securing specialty services. The lack of a KAC item specifically addressing community service linkages may well account for the lack of any significantly positive correlations with PCMH-A item 34 (designating a staff person to coordinate with community agencies).

Our best-practice organizations, but only a few SNMHI sites, track and support patients through the referral or transition process. Of the 3 key activities linked with supporting patients, 2 were significantly correlated with routinely following up with patients seen in the hospital or ED. In a few SNMHI organizations, referral coordinators or managers (generally administrative not nursing staff) guide and track patients referred outside the practice, help make appointments, and ensure that information transfer proceeds smoothly. Only 1 key activity—develop systems that support the safe transition of patients—addressed patient support; its somewhat opaque wording may account for its lack of correlation with the PCMH-A items.

Establishing connections between providers that facilitate communication and the timely transfer of patient information is an essential dimension of effective care coordination. One key activity is the development of an information transfer system for these purposes. This activity was significantly correlated with PCMH-A item 33—providing follow-up care to patients seen in the ED or hospital. It was not, however, correlated with PCMH-A item 32—obtaining needed referrals with relevant information communicated in advance. This analysis suggests that SNMHI practices devoted more effort to improving transitions than to improving referrals.

There are several limitations to this analysis. First, the items used in the analysis are all reported by the practice, and may well be exaggerated or biased to make the practice appear to be more actively engaged in transformation than they actually are. For these reasons, one might expect them to be positively correlated. Second, the PCMH-A does not measure the quality of care coordination from the perspectives of either patients or providers. It only assesses whether a practice has systems and relationships in place to better coordinate care. Third, both instruments have similar conceptual roots so that positive correlations might be expected. However, the fact that many of the correlations were negative or very close to zero, including some that we expected to be positive, provides some assurance that the significantly positive correlations identify actions that may well contribute to better care coordination. Finally, the results pertain to safety-net practices, and may not generalize to other primary care settings.

The Care Coordination Model recommends that primary care assume accountability for improving care coordination, develop relationships with key partners in care, support patients as they obtain care outside the practice, and ensure the timely flow of key patient information. This preliminary look at the experience of SNMHI practices in trying to improve care coordination suggests that actions consistent with the model lead to system changes that facilitate more coordinated care. The validity of the Care Coordination Model will remain in question until it can be shown to improve patient experience and outcomes, provider experience, and reduce medical errors and unnecessary costs.


The authors are grateful for the contributions of Kathryn Horner, Judith Schaefer, and Dona Cutsogeorge to the research that led to the Care Coordination Model.


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Care Coordination Model; primary care; patient-centered care; practice change

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