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Reducing Care Fragmentation

Care coordination is “the deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services.” [1]  In this definition, all providers working with a particular patient share important clinical information and have clear, shared expectations about their roles.  Equally important, they work together to keep patients and their families informed and to ensure that effective referrals and transitions take place.

“Reducing Care Fragmentation: A Toolkit for Coordinating Care” was designed for clinics, practices, and health systems focused on improving care coordination by transforming the way they manage patient referrals and transitions.  Providing coordinated care is an essential feature of any patient-centered medical home (PCMH)— and one that can be challenging to implement.  This toolkit was created to make it easier.


The toolkit contains practical strategies and clinical resources to help you implement specific practice changes designed to help make care coordination easier.

  • First we present the stories of Ms. G and Ms. H to illustrate what care coordination means and why achieving it is so important—and so challenging.
  • Next, the toolkit introduces a Care Coordination Model based on key concepts that contribute to successful referrals and care transitions.
  • The toolkit then describes six key changes that support the model, and identifies resources to facilitate each change.
  • To illustrate real-world examples of improved care coordination, the toolkit follows with five case studies from diverse settings—including a small family care network, a safety net public hospital, and a regionally integrated health system delivering comprehensive care.
  • In the final section, you’ll find an index of the recommended tools and resources, along with the tools themselves (or information on how to find them.)


Suggested citation: Reducing Care Fragmentation: A Toolkit for Coordinating Care. (Prepared by Group Health’s MacColl Institute for Healthcare Innovation, supported by The Commonwealth Fund), April 2011.



Richard C. Antonelli, MD, MS, FAAP
Children's Hospital Boston

Philip Renner, MBA
National Committee for Quality Assurance

Edward L. Schor, MD
The Commonwealth Fund

Jennifer May, MPH
National Academy for State Health Policy

Alan Glaseroff, MD
Humboldt-Del Norte IPA

Katie Vinson
Humbodlt-Del Norte IPA

Alice Chen, MD, MPH
San Francisco General Hospital

Hal F. Yee, Jr., MD, PhD
San Francisco General Hospital

Robert J. Reid, MD, PhD
Group Health Cooperative

Janice Hess
Group Health Cooperative

Suzanne Swadener, RN, MHA 
Group Health Cooperative

Ann S. O'Malley, MD, MPH
Center for Studying Health System Change

Trissa L. Torres MD
Genesys Health System

David C. Kendrick, MD, MPH
University of OK School of Community Medicine

















MacColl Institute for Healthcare Innovation project team:

Ed Wagner, MD, MPH, MACP
Judith Schaefer, MPH
Kathryn Horner, MS
Dona Cutsogeorge, MA
Rick Perrault

The toolkit, "Reducing Care Fragmentation:  A Toolkit For Coordinating Care", is supported by The Commonwealth Fund, a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy.  The view presented here are those of the authors, and not necessarily those of The Commonwealth Fund, its directors, officers, or staff.