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Coordination Within Medical Neighborhoods: Insights from the Early Experiences of Colorado Patient-Centered Medical Homes

people health insurance


A central goal of patient-centered medical homes (PCMHs) is coordinating needed services for patients. PCMHs could further reduce fragmentation by serving as communication hubs for the hospitals, specialists, and primary care providers that make up a “medical neighborhood.” To understand how PCMHs help to exchange information and coordinate care, Commonwealth Fund–supported researchers studied the practices of 13 patient-centered medical homes in Colorado.

What the Study Found

For relatively straightforward care coordination needs—a referral for a cancer screening or notification of a hospital admission—most PCMHs relied on routine and sometimes automated workflows, including electronic systems for tracking tests or referrals or for following up on patients admitted to the hospital. Sharing electronic medical records with specialists also helped with the exchange of clinical information, but fewer than one-third of the PCMHs had that capability.

When diagnosis was less certain and required consultation among providers, PCMHs used their staff members to bridge communication. Eight of the 13 medical homes had a dedicated position for this, called care coordinator or referral specialist. In medical homes without a dedicated coordinator, the responsibility was shared among staff members.

For more complex cases, four PCMHs used “care compacts” with specialists that spelled out expectations for communication and collaboration. Some medical homes had introduced accountability mechanisms such as measuring specialist performance through the use of report cards, patient surveys, and real-time feedback. None had care compacts with hospitals.

The barriers to effective care coordination included a lack of interoperable electronic systems; difficulties in recruiting, training, and retaining care coordinators; and misaligned payment incentives.


The optimal mix of care coordination tools depends on the population of patients, their needs, and the willingness of partners to collaborate with one another.

Publication Details



Shehnaz Alidina, Associate Director, Safe Surgery 2020, Harvard Medical School

[email protected]


S. Alidina, M. Rosenthal, E. Schneider et al., “Coordination Within Medical Neighborhoods: Insights from the Early Experiences of Colorado Patient-Centered Medical Homes,” Health Care Management Review, April/June 2016 41(2):101–12.