Coordinating care--a perilous journey through the health care system.

In the United States, 125 million people are living with chronic illness, disability, or functional limitation.1 The nature of modern medicine requires that these patients receive assistance from a number of different care providers. Between 2000 and 2002, the typical Medicare beneficiary saw a median of two primary care physicians and five specialists each year, in addition to accessing diagnostic, pharmacy, and other services. Patients with several chronic conditions may visit up to 16 physicians in a year.2 Care among multiple providers must be coordinated to avoid wasteful duplication of diagnostic testing, perilous polypharmacy, and confusion about conflicting care plans. The particularities of American health care, with its pluralistic delivery system that features large numbers of small providers, magnify the number of venues such patients need to visit. Care must be coordinated among primary care physicians, specialists, diagnostic centers, pharmacies, home care agencies, acute care hospitals, skilled nursing facilities, and emergency departments. Within each of these centers, a patient may be touched by a number of physicians, nurses, medical assistants, pharmacists, and other caregivers, who also need to coordinate with one another. Given this level of complexity, the coordination of care among multiple independent providers becomes an enormous challenge. Care coordination has been defined as “the deliberate integration of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services.”3 Not only is care coordination needed among multiple providers, but coordination is also required between providers and patients and their families. Particularly for young children and elderly patients, the number of coordination relationships can multiply geometrically in the not-unusual case of three different provider organizations (with several caregivers in each organization) having to interact with a patient plus three distinct family members. Care coordination is required when traditional continuity of care — the relationship between a single practitioner and a patient that extends beyond specific episodes of illness or disease4 — is lacking. Continuity and fragmentation of care can be viewed as opposite ends of a spectrum. In unusual cases in which continuity is nearly total, coordination is rarely needed. In the most common situation in which continuity is limited and care is fragmented, coordination is essential. This report assesses the quality of care coordination, lists barriers to coordinated care, and discusses some solutions to improve care coordination.