A heart failure patient sees a cardiologist, a primary care physician, a nutritionist, and a home health nurse. They take eight medications prescribed by three different providers. They were discharged from the hospital last week and have a follow-up in two days. If any one of these providers doesn’t know what the others are doing — missed medication changes, duplicated tests, conflicting care plans — the patient ends up back in the emergency department. Care coordination is the system that prevents this, ensuring every provider on the team has the same information and is working from the same plan.
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Care coordination is the deliberate organization of patient care activities between two or more participants involved in a patient’s care — including the patient — to facilitate the appropriate delivery of healthcare services. In health IT, care coordination refers to the technology platforms, data exchange workflows, and communication tools that enable providers across settings to share information, align on care plans, and manage transitions of care.
The Agency for Healthcare Research and Quality (AHRQ) defines care coordination as the function that helps ensure the patient’s needs and preferences for health services are met over time — bridging gaps between providers, settings, and episodes of care.
Care coordination is not a single application — it’s a capability that spans multiple systems: EHRs for clinical documentation, health information exchanges for cross-organizational data sharing, ADT notification feeds for event-driven alerts, patient portals for patient engagement, and dedicated care management platforms for longitudinal care planning and follow-up.
Care coordination has become a strategic priority because of the shift toward value-based care — payment models that hold providers financially accountable for outcomes, readmission rates, and total cost of care. When an avoidable readmission costs a health system $15,000 in penalties, investing in care coordination technology becomes a financial imperative, not just a clinical nicety.
In simple terms: Care coordination is the technology and process that keeps every provider on the same page for every patient — sharing care plans, managing transitions, and preventing the gaps that lead to poor outcomes and unnecessary costs.
Care coordination platforms manage several interconnected workflows — care transitions, shared care plans, team communication, and proactive patient outreach.
Care transitions. The most critical care coordination use case. When a patient moves between settings — hospital to home, ED to primary care, inpatient to skilled nursing — clinical information must travel with them. The discharging facility generates a C-CDA transition of care document containing discharge diagnoses, medications at discharge, follow-up appointments, and care instructions. The document is transmitted to the receiving provider through a health information exchange or Direct messaging. The receiving provider reconciles the incoming data with their existing record and initiates post-transition follow-up.
ADT-based event notifications. Real-time ADT messages sent through HIE networks notify care teams when patients are admitted to or discharged from hospitals. A primary care practice receives an alert that their patient was admitted to a hospital across town. A care manager receives notification that a high-risk patient was just discharged and needs immediate follow-up. These notifications enable proactive intervention rather than discovering the event days or weeks later.
Shared care plans. For patients with complex needs — multiple chronic conditions, behavioral health comorbidities, social determinant barriers — a shared care plan documents goals, planned interventions, responsible providers, and target outcomes. The care plan is accessible to all members of the care team and updated as the patient’s condition and circumstances change. FHIR CarePlan resources provide a standardized way to represent and exchange care plans across systems.
Care team communication. Secure messaging, task assignment, and notification tools enable communication among providers who may be in different organizations, using different EHR systems. A care coordinator sends a message to the patient’s PCP about a medication concern. A specialist flags a test result for the referring physician. A home health nurse reports a change in patient status. These communications must be documented and accessible within the patient’s longitudinal record.
Patient engagement. Effective care coordination includes the patient. Patient portals, mHealth apps, and telehealth visits keep patients connected to their care plan, enable symptom reporting between visits, and support medication adherence. Remote patient monitoring extends care coordination into the patient’s home — continuous data feeds alert care teams to deterioration before it becomes an emergency.
Referral management. Care coordination includes managing referrals between providers — tracking referral status, ensuring the specialist receives relevant clinical context, and confirming the patient completed the referred visit. Closed-loop referral tracking prevents patients from falling through cracks between organizations.
Consolidated CDA documents — particularly the Continuity of Care Document (CCD), Discharge Summary, and Referral Note — are the primary mechanism for exchanging clinical information during care transitions. C-CDA documents carry structured medication lists, problem lists, allergies, and care instructions that the receiving provider’s EHR can parse and import.
FHIR provides dedicated resources for care coordination: CarePlan (goals, activities, and team composition), CareTeam (providers involved in a patient’s care), Goal (patient health objectives), Task (assigned activities with status tracking), and Communication (messages between care team members). These resources enable standardized care plan exchange across systems.
ADT event notifications routed through HIEs are a foundational care coordination mechanism. CMS has encouraged ADT-based notification programs, and several states mandate that hospitals send admission and discharge notifications to primary care and post-acute providers through state HIEs.
The HL7 Gravity Project defines FHIR-based workflows for social determinant screening, referral to community resources, and closed-loop outcome tracking. SDoH-integrated care coordination connects clinical providers with community-based organizations — food banks, housing assistance, transportation services — to address the non-clinical factors that drive readmissions and poor outcomes.
CMS reimburses care coordination through several programs: Chronic Care Management (CCM) — monthly care coordination for patients with two or more chronic conditions. Transitional Care Management (TCM) — post-discharge coordination during the first 30 days. Principal Care Management (PCM) — care management for a single complex chronic condition. Each program has specific documentation, billing, and time requirements that care coordination platforms must support.
Care coordination implementation spans clinical workflow design, technology integration, organizational partnerships, and reimbursement optimization.
Cross-organizational data sharing is the foundation. Care coordination only works when providers across organizations can share data. This requires HIE connectivity, C-CDA document exchange capabilities, and increasingly, FHIR-based data access. If your organization doesn’t participate in an HIE or can’t exchange documents with referral partners, care coordination remains incomplete.
Care management platform selection. Dedicated care management platforms (population health tools, care coordination hubs) provide workflow capabilities beyond what most EHRs offer — risk-stratified patient lists, care plan management, task assignment across organizations, and longitudinal tracking across encounters and settings. Evaluate whether your EHR’s built-in care management module is sufficient or whether a specialized platform is needed.
Population health analytics drive targeting. Not every patient needs intensive care coordination — resources should be focused on patients at highest risk for adverse events, readmissions, and avoidable utilization. Risk stratification models that incorporate clinical data, claims data, SDoH factors, and utilization patterns identify the patients who will benefit most from proactive coordination.
Staff roles and workflows matter more than technology. Care coordinators, case managers, social workers, and community health workers are the human infrastructure of care coordination. Technology enables their work but doesn’t replace it. Define roles clearly, design workflows that minimize administrative burden, and measure outcomes at both the patient and program level.
Billing captures the value. CMS CCM, TCM, and PCM programs provide reimbursement for care coordination services — but only if documentation requirements are met. Care coordination platforms must track time spent, document patient interactions, and generate billing-ready data for CPT code submission through the revenue cycle.
Consent and privacy. Sharing patient data across organizations for care coordination requires appropriate consent and HIPAA compliance. Behavioral health records (42 CFR Part 2), substance use data, and state-specific privacy laws add layers of consent complexity. Build consent management into your care coordination infrastructure.
At Taction, our team builds care coordination platforms, integration infrastructure, and data exchange capabilities for health systems, provider networks, and care management organizations.
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