Providers, health systems, health plans, disease management companies and the like are trying to assist patients through the complex maze of care delivery. As a result, we have an excess of care coordinators — care managers, case managers, disease managers, health educators and others of varying titles, but who fill the same role and responsibilities.


Although the value of these skilled care coordinators is unclear from a return on investment perspective, there is no doubt that many patients can benefit from these programs. However, providers of these services unwittingly can create too many silos of care and confuse patients.

Consider the sample case of Mr. Smith, a 72-year-old man with congestive heart failure and diabetes.

An Unnecessary Readmission

Mr. Smith is enrolled in a Medicare Advantage plan aligned with a high-profile integrated delivery system. He has a primary care physician he has known for many years and whom he respects. Upon enrolling with the Medicare plan, Mr. Smith was assigned to Carol, a care coordinator with whom he has a good relationship.

Recently Mr. Smith was hospitalized. He was admitted by a hospitalist who is a friend of his physician. While an inpatient, Mr. Smith met Sally, his inpatient utilization case manager, and Beth, the inpatient clinical care coordinator. Since there was a concern that Mr. Smith's CHF was deteriorating, the hospitalist (without notifying his primary care physician) recommended he be seen in the CHF clinic, and there he met Bob, his CHF care coordinator.

When he was discharged, Mr. Smith received a transitional care plan and met Maggie, who would be his transitional care coordinator.

While each care coordinator had Mr. Smith's best interests at heart, none of them had the same plan or goals of care. Since several care coordinators attempted to develop new goals for Mr. Smith, he became puzzled and concerned, given that his primary physician was not involved.

As a result, when Mr. Smith became ill at home one day after discharge, he was unsure whom to call. Consequently, his wife just called 911, and Mr. Smith had an unnecessary readmission despite having multiple, skilled care coordinators to help him get the most appropriate care.

Centralizing Care Coordination

In an ideal, centralized care coordination program, the care team develops a seamless path for patients. All the care coordinators work from a single care plan developed by the patient's primary care coordinator in conjunction with the patient's primary care physician and team of care coordinators when appropriate. When or if the physician makes a transition to a medical home model, the primary care coordinator can be literally or virtually integrated into that site.

The care coordination team has the patient history available and can discuss each role and need in relation to a care plan that engaged Mr. Smith. Many of the care coordinator job functions can be consolidated into another coordinator's role, leading to reduced staff overall and fewer handoffs, which gives more patients access to care coordinator services.

The nature of hospitals and health systems inherently creates care navigation silos. The challenges of centralized care coordination include the following:

  • There is an organizational infrastructure with each care coordinator reporting to a different department (and senior leaders) in the hospital or health system. Often these departments have competing goals and agendas. One care coordinator may be responsible for managing inpatient length of stay, another may oversee disease-specific problems, and yet another may be focused on post-discharge needs.
  • The senior leaders of these different departments are not engaged and do not have true system goals as performance metrics.
  • Vendor relationships for external care coordination are not addressed and integrated. Often, there are redundant and conflicting care plans and goals.
  • An integrated electronic health record that spans the continuum of care is not available.
  • Continuum care coordination training among the numerous care coordination personnel is lacking.
  • Training in patient coaching and engagement is absent.
  • Standardized metrics for evaluation of care coordination results do not exist.
  • There is no integrated hospitalist program.
  • Physicians do not engage well in care coordination.

While each organization may have challenges unique to its structure, it needs a plan that develops the necessary skills, aligns goals for coordination across the continuum, and measures results anchored in improved quality and utilization for patients.

Questions for Reflection

To determine if the care coordination staff is creating silos, consider the following:

  • Throughout the infrastructure, do the care coordinators report to different departments (e.g., nursing, quality or utilization review)?
  • If the hospital or health system is aligned with a major payer, have there been enough discussions regarding movement of the payer's members within the hospital or system?
  • Do the care coordinators need to share more information on patient engagement and standard evidence-based care maps?
  • Are others failing to identify care coordinators in initial inpatient assessments as part of the care delivery team?
  • Are there high admission and readmission rates for diseases in which a seamless care plan could help (e.g., CHF or ambulatory-sensitive conditions)?

If the answers to these questions cause concern, the hospital or health system should look into centralizing care coordination services.

Teresa Koenig, M.D., M.B.A., is a vice president at The Camden Group in Los Angeles.