Care Coordination
Core concepts
Care coordination is the deliberate organization of patient care activities and information sharing among participants to achieve safer, more effective care. The CNL must know the patient’s goals, the care plan, who is accountable for each action, and how information moves between settings and disciplines. Distinguish coordination from case management: case management often emphasizes utilization, authorization, and financial resources, while care coordination emphasizes clinical integration and continuity. Key concepts include multidisciplinary care planning, closed-loop communication, handoffs, medication reconciliation, resource referral, and patient/caregiver engagement.
Traps
Questions often imply that coordination means scheduling appointments only, that one discipline owns the plan, or that a message sent equals a message received. Another trap is overlooking patient preferences and social needs, which undermines adherence. Candidates may also confuse documentation with coordination: a plan in the record is not coordinated unless roles, next actions, and follow-up are clear.
Worked example
An older adult with heart failure and diabetes has four prescribers and two pharmacies. The CNL convenes a brief team huddle, confirms the patient’s goal (stay home), assigns one accountable coordinator, performs medication reconciliation, schedules a follow-up visit, and documents each action with an owner and due date. The patient uses teach-back to state the plan.
Rule of thumb
One patient-centered plan, one accountable coordinator, and for every action a named owner, timeline, and confirmation loop.