We live in a time where patients are increasingly being treated by multiple caregivers, providers and stakeholders.

Now more than ever, it is essential to have care coordination between all these groups to ensure the best health outcomes for patients in particular to meet the needs of the five per cent that account for half of healthcare costs. These are the most active users of the system with multiple, complex conditions.

When a hospital, primary care physician, long-term care home, community organizations and others work in a coordinated fashion, the patient becomes the centre of care and benefits from an integrated care model. Healthcare providers design a care plan for each complex needs patient and work with them and their families to ensure continuity of care.

This community-focused health model has been an aim for years around the world, and it makes sense, both economically and from a health perspective, especially in the case of chronic disease, the leading cause of death and disability.

As a primary care physician, I believe that coordinated care can do much to help by leading a community based effort to improve outcomes.  In order to do so however, it is increasingly obvious that continuity of care is only possible with integration of information across the community and use of a single care plan that links the efforts of all providers involved in the care of each patient.

As it stands in many countries, patient information is often fragmented and silo’d in individual healthcare facilities resulting in the reality that clinicians often lack the means to access complete information when they see their patients. This often leaves a patient having to undergo repeated tests and the potential for medication errors. Their care cannot be coordinated without integration of information. From a provider perspective, it’s a lot of unnecessary work for clinicians to have to manually re-enter data in a way that seems intuitively unnecessary.  

For care to be coordinated it needs to be “wrapped around the patient” in a single care plan that can be accessed and contributed to by all providers. Improved care coordination has been shown to have positive impacts across the system. Evidence shows that, in addition to technology, face-to-face and home visits significantly improve outcomes for these patients. In addition, hospital readmission rates are reduced in a range of environments and settings. 

Care coordination is not a new idea - community nurses for instance have promoted the evolution of care coordination for many years. Now however we have an opportunity to go beyond simple case management to create integrated, coordinated care plans that include both clinical and patient descriptions of ongoing issues, next steps to be taken, perceived patient risks and contact information for all stakeholders.

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