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Health care professionals notice failures in coordination particularly when the patient is directed to the "wrong" place in the health care system or has a poor health outcome as a result of poor handoffs or inadequate information exchanges.
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Care coordination addresses potential gaps in meeting patients' interrelated medical, social, developmental, behavioral, educational, informal support system, and financial needs in order to achieve optimal health, wellness, or end-of-life outcomes, according to patient preferences. Clinical coordination involves determining where to send the patient next (e.g., sequencing among specialists), what information about the patient is necessary to transfer among health care entities, and how accountability and responsibility is managed among all health care professionals (doctors, nurses, social workers, care managers, supporting staff, etc.). Care coordination is a patient- and family-centered, team-based activity designed to assess and meet the needs of patients, while helping them navigate effectively and efficiently through the health care system. Patients perceive failures in terms of unreasonable levels of effort required on the part of themselves or their informal caregivers in order to meet care needs during transitions among health care entities. Transitions may occur between health care entities (see definition under "additional terms") and over time and are characterized by shifts in responsibility and information flow. Patients, their families, and other informal caregivers experience failures in coordination particularly at points of transition. Care coordination is any activity that helps ensure that the patient's needs and preferences for health services and information sharing across people, functions, and sites are met over time. Consideration of views from these three potentially different perspectives is likely to be important for measuring care coordination comprehensively. Successes and failures in care coordination will be perceived (and may be measured) in different ways depending on the perspective: patient/family, health care professional(s), or system representative(s). For a given patient at a given point in time, the bridges or ring need to form across the applicable circles, and through any gaps within a given circle, to deliver coordinated care. The blue ring that connects the colored circles is Care Coordination-namely, anything that bridges gaps (white spaces) along the care pathway (i.e., care coordination activities or broad approaches hypothesized to improve coordination of care). The colored circles represent some of the possible participants, settings, and information important to care pathways and workflow. The central goal of care coordination is shown in the middle of the diagram. Several additional illustrations of care coordination are presented in a recent monograph on quality of cancer care. This visual definition may be helpful to some Atlas users, and less so to others. In this section we provide a visual definition ( go to Figure 1) and scenarios to help illustrate care coordination in the absence of a consensus definition. This lack of consensus is perhaps not surprising given the many different participants involved in coordinating care. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care." For some purposes, they noted that other definitions may be more appropriate. A recent systematic review identified over 40 definitions of the term "care coordination." 2 The systematic review authors combined the common elements from many definitions to develop one working definition for use in identifying reviews of interventions in the vicinity of care coordination and, as a result, developed a purposely broad definition: "Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services.
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Care coordination means different things to different people no consensus definition has fully evolved.