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The Care Coordination Imperative: Responding to the Needs of People with Chronic Diseases


The changing landscape of health and disease in the 21st century calls for a concerted response from the health care delivery system. That health care consumes 17 percent of U.S. gross domestic product is alarming, but the change in Americans' health status—one of the underlying drivers of costs—is equally staggering. The increasing prevalence of chronic illness among Americans, even as life expectancy grows and the population ages, poses major challenges to the medical profession and the entire health care system.

Nearly half of all Americans live with at least one chronic condition, and care for these patients is complex, often involving a number of clinical, occupational, and social services. One study found that the typical primary care doctor has the potential to interact with as many as 229 other doctors, in 117 different practices. Another recent study found that the probability that a physician visit would result in a referral to another physician increased from 4.8 percent in 1999 to 9.3 percent in 2009, a 94 percent increase. The absolute number of ambulatory care visits that resulted in a referral more than doubled in this 10-year period.

The latest Commonwealth Fund International Survey examines care coordination, chronic care management, and patient engagement among "sicker" adults in 11 nations . Every country faces particular challenges in caring for the rising number of people with chronic conditions, hence there is a unique opportunity to share and learn from various approaches. In the US, 23 percent of respondents with chronic conditions saw four or more doctors over the last year. Medication management for such patients is particularly complicated; 46 percent of this same group said they were taking four or more prescription drugs on a regular basis.

Not surprising, given this complexity, the survey found problems with care coordination. Patients said that they often experienced problems obtaining medical records and test results, which increased with the number of doctors seen. Thirty percent of U.S. adults with chronic conditions who had four or more doctors reported a coordination problem with test or records, compared with 24 percent of those with one or two doctors.

Coordination is a multifaceted activity that requires effective participation among many different professionals, service organizations, and—of course—the patient. However, even today, the patient is often an afterthought. While there is strong evidence that a key to successful chronic care management is engaging patients in their care, only about half of those with chronic conditions in the U.S.—and in several of the other countries surveyed—say that their regular doctor always tells them about treatment options and involves them in decisions.

Many physician practices may not be set up to serve patients with chronic conditions. Physicians still function as soloists: studies have shown that only 35 percent said that improved teamwork and communication are very effective ways to improve quality of care. And physicians' views of how well they work as part of a team—in terms of communication and collaboration—are much higher than those of the nurses and other team members.

A 2009 survey found that 41 percent of U.S. physicians say their practices function without non-physician staff, such as social workers or nurse case managers, to help manage the care of their patients.

So How Can We Get It Together?
Models of care coordination are not new. The principles of the "medical home" were first proposed by the American Academy of Pediatrics in 1967 for the care of special needs children. The chronic care model has been developed and tested over the past 15 years. So the real challenge is not what to do, but how to do it. It is a question of execution, and even more so of scalability. Organizing the delivery of care to respond to the needs of patients, particularly those with chronic conditions, requires crossing traditional institutional boundaries and creating networks that threaten a health care culture that is currently based on professional and institutional autonomy.

Fortunately, medical education is adapting to the changing landscape. Increasingly young doctors in training are exposed to teamwork both across medical specialties and across health professions, including nursing and pharmacy. Residency training programs, professional organizations, and certifying boards can help ensure that team training is valued as an essential competency.

But the environment in which physicians practice also needs to change to support these care models. The Affordable Care Act provides unique opportunities to organize the delivery system and build a strong primary care practice infrastructure that will help improve care coordination. For example, the law established the Primary Care Extension program, which will be administered by the Agency for Healthcare Research and Quality to provide support to primary care providers. State or multistate hubs and local programs will inform providers about best practices in preventive medicine and chronic disease management, and provide technical assistance to help them implement evidence-based treatment approaches.

A number of training demonstrations will invest in coordinated care teams that include primary care physicians, midlevel providers such as nurse practitioners, and community-based social services providers. Grants and contracts will support medical homes through community health teams, thereby increasing access to coordinated care. Most recently, the Centers for Medicare and Medicaid Services announced the Health Care Innovation Challenge, which provides $1 billion in funding for initiatives that hire, train, and deploy health care workers. That funding is available to physicians, community groups, local government, and other organizations that work with patients with Medicare and Medicaid.

Given these opportunities, how will we know whether we are successful? First, we need to set explicit short- and longer-term targets and monitor progress. For example, what if by 2013—the next time The Commonwealth Fund will survey adults with chronic conditions—we set a target of reducing the number of patients experiencing care coordination problems by 30 percent? And perhaps we can go from 58 percent of patients saying they are engaged in their care to 70 percent in 2013, and 90 percent by 2023. These measures of coordination and engagement could certainly be tracked as new models of care such as medical homes and accountable care organizations are implemented.

The important lessons here are that we need a concerted effort and an overarching strategy to support the changes in the delivery system required to achieve seamless care and the health outcomes we seek. Tracking progress with comparative information and performance benchmarking is essential. In addition, attention needs to be given to strengthening primary care and to developing multidisciplinary teams that can oversee the care of people over time. We need to ensure practices receive technical assistance to help them redesign the way they deliver care. And we need continued investment into health information technology and health information exchange to support care teams, patients, and caregivers. Finally, incentives have to be aligned to remove barriers to implementing efficient models of care, and to reward better quality, better health, and the efficient use of resources.

Publication Details



A. M. Audet, S. Patel, The Care Coordination Imperative: Responding to the Needs of People with Chronic Diseases, The Commonwealth Fund Blog, February 2012.