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Care Continuity and Care Coordination:  What Counts?

Lena M. Chen, MD, MS1,2,3,4; John Z. Ayanian, MD, MPP1,3,5,6
[+] Author Affiliations
1Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
2VA Ann Arbor Healthcare System, Ann Arbor, Michigan
3Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
4Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
5Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
6Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor
JAMA Intern Med. 2014;174(5):749-750. doi:10.1001/jamainternmed.2013.14331.
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Improving care coordination has emerged as a key strategy of many payers and policymakers for enhancing the quality and lowering the costs of health care in the United States. Accountable care organizations and bundled payments aim to bridge the provider-based silos that fragment care. Patient-centered medical homes (PCMHs) seek to coordinate the care of patients with chronic disease. And recent changes to Medicare physician payments provide explicit incentives to enhance transitional care, such as the transition from hospital to outpatient care. To determine if care coordination does indeed have positive effects on quality or cost, the first step is to decide how it can be measured.

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Figure.
Conceptual Model of the Relationship between Care Continuity and Care Coordination

Illustrative examples. A, Fragmented care (not continuous or coordinated): Patient sees 7 different physicians, each of whom has an incomplete knowledge of the others’ actions and the patient’s goals of care. B, Continuous care that is not well coordinated: Patient makes 5 visits to Dr X and 2 visits to Dr Y, each of whom has an incomplete knowledge of the other’s actions and the patient’s goals of care. C, Continuous and coordinated care: Patient makes 5 visits to Dr X and 2 visits to Dr Y, both of whom work closely together to achieve common, patient-centered goals of care.

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