Coordinating Care -- A Perilous Journey through the Health Care System

Thomas Bodenheimer, M.D.

In the United States, 125 million people are living with chronic
illness, disability, or functional limitation. 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. 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." 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.

Coordinating Care -- How Are We Doing?

Recent research strongly suggests that failures in the coordination of
care are common and can create serious quality concerns. Table 1 lists
several studies documenting some of these problems. For example,
referrals from primary care physicians to specialists often include
insufficient information, and consultation reports from specialists
back to primary care physicians are often late and inadequate. When
patients are hospitalized, their primary care physicians may not be
notified at the time of discharge, and discharge summaries may contain
insufficient information or never reach the primary care practice at
all. The studies listed in Table 1 do not comprise a rigorous review
of the literature but provide examples of the kinds of difficulties in
care coordination that patients and their families and caregivers
face. In addition to research studies, the voices of patients and
their families remind us that the coordination of their care among
multiple providers is often flawed.

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