Care coordination

Definition

Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) to facilitate appropriate delivery of health care services. This commonly-used US healthcare policy definition is drawn from the Agency for Healthcare Research and Quality (AHRQ), which has been a primary source for the national definition and measurement framework.

In practice, care coordination spans inpatient-to-outpatient transitions, ongoing chronic care management, medication reconciliation, specialist referral and follow-up scheduling, patient and caregiver education, and cross-specialty communication. It is both a clinical function and an organizational capability \u2014 one that CMS has progressively built reimbursement frameworks around to incentivize structured coordination activities in outpatient and community settings.

Regulatory basis

AHRQ has been the primary source for the US definition and measurement framework for care coordination, publishing evidence reviews and toolkits used by CMS, payers, and health systems. CMS has translated these frameworks into reimbursable programs under the Medicare Physician Fee Schedule: Transitional Care Management (TCM) for the post-discharge transition, Chronic Care Management (CCM) for patients with two or more chronic conditions, and Principal Care Management (PCM) for single-condition management. Details on TCM reimbursement specifics \u2014 including contact requirements, billing codes, and documentation standards \u2014 are available in the CMS Medicare Learning Network TCM fact sheet.

Together, TCM, CCM, and PCM give providers a reimbursement pathway for structured care coordination work that has historically been uncompensated. Quality measurement programs \u2014 including HEDIS, CMS Star Ratings, and value-based contract metrics \u2014 further reinforce care coordination by tying it to financial performance across payer types.

Who uses it and when it applies

• Primary care physicians and specialist groups managing patients with chronic conditions or recent hospital discharges
• Accountable Care Organizations (ACOs) whose shared savings programs depend on reducing fragmented, duplicative, or poorly timed care
• Care coordinators, care managers, and clinical staff performing non-face-to-face services under general or direct supervision
• Quality leadership measuring patient experience and care transition metrics for CMS, NCQA, or commercial payer reporting

Related terms

• Transitional Care Management (TCM) \u2014 the CMS-reimbursed post-discharge coordination program
• 30-day readmission \u2014 a clinical outcome care coordination aims to reduce
• CPT 99495 \u2014 a billing code enabling reimbursed care coordination

How Positive Check relates

Positive Check automates the patient-engagement layer of care coordination \u2014 consistent daily or weekly wellness check-ins, structured data capture, and real-time escalation to clinical staff. See the Post-Discharge Follow-Up solution for how automated wellness calls fit a care coordination workflow.