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Our funding for updating this website ended in 2011, but the resources we developed are still helping clinical practices from around the world to transform the care they provide to better serve patients with chronic illness. Please visit our home page to learn more—or check out our more recent tools and resources at:



[download Care Coordination Model PDF] 
Unlike other aspects of medical care, there has been relatively little rigorous research to direct efforts to improve care coordination. However, many innovative health care organizations have recognized the dangers of poorly coordinated care and have implemented interventions to improve it. The recommendations in this toolkit derive from both the scientific literature, when available, and the best ideas from the field. We have assembled the best evidence in a Care Coordination Model.
The goal of care coordination is high-quality referrals and transitions that meet the six Institute of Medicine "Quality Chasm" aims for high-quality health care, and assure that all involved providers, institutions and patients have the information and resources they need to optimize a patient’s care. (9) The Model looks at care coordination from the perspective of a patient-centered medical home (PCMH). It considers the major external providers and organizations with which a PCMH must interact—medical specialists, community service agencies, and hospital and emergency facilities—and summarizes the elements that appear to contribute to successful referrals and transitions. Those elements include:
  • Assuming accountability
  • Providing patient support
  • Building relationships and agreements among providers (including community agencies) that lead to shared expectations for communication and care
  • Developing connectivity via electronic or other information pathways that encourage timely and effective information flow between providers (including community agencies)