Care Coordination Mapping: Variations By Service Delivery Model

Care coordination is a key element in reform strategies aimed at bending the health care cost curve for high-cost and high-need consumers. There is little difference between “care management,” “case management,” and “care coordination.” While the terms can be – and are – used interchangeably, care coordination has a more comprehensive connotation – i.e., it captures the need to facilitate and manage care for chronic care clients across a multiplicity of settings for a full array of social, medical, and behavioral health services.

Care coordination is a feature of all service delivery models. What distinguishes emerging models for care coordination from earlier models is the supporting infrastructure – technology to support connectivity – and the capacity to manage care coordination and transitions of care. New care coordination efforts are underway in 25 states in fiscal year (FY) 2013 and planned in 33 more states for FY 2014. These initiatives take many forms but include Medicaid health homes, patient-centered medical homes (PCMHs), and Medicaid accountable care organizations (ACOs).

All care coordination models share similar goals – to address the cost of serving high cost/high needs beneficiaries while improving their quality of care. The primary cost drivers for high cost/high need beneficiaries are institutional care: Emergency Department (ED) use, Hospital readmissions, and Nursing home/skilled nursing. Care coordination processes seek to reduce the demand and need for institutional care by connecting these patients to needed social, behavioral, and medical supports in a more timely and coordinated (less duplicative) fashion.

With these goals in mind, elements of care coordination common to all care coordination models include:

1. Identification and targeting of intensive‐level care coordination efforts on high cost/high need patients in an effort to reduce care fragmentation that impacts both cost and quality of care
2. Provision of patient supports to assess and address a patient’s clinical, insurance, and logistical needs in an effort to reduce missed appointments and contributes to readmissions due to failed transitions between care settings
3. Focus on education to support patient engagement and self‐management