JUNE 10-14, 2019   •  Las Vegas, NV
Navigating the Full Spectrum of Case Management • Mirage Convention Center

PP313 – Care Coordination: A Model Based on the Continuum of Care

PP313 – Care Coordination: A Model Based on the Continuum of Care

Care Coordination is the deliberate organization of patient care and information sharing to achieve safe and effective care. Defining levels of care coordination along a continuum creates a practical approach to the organization of services, tools and processes that match the patient complexity and service intensity, assisting in staffing requirements. The Veterans Health Administration (VHA) approach conceptualizes care coordination along a continuum and stratifies patients into three distinct levels: basic, moderate, and complex. Basic care coordination provides the services of system navigation and referral performed by clinical or non-clinical staff as a short-tem, low intensity intervention. Moderate care coordination provides health promotion, disease prevention and chronic disease management using population tools. Patients receive moderate care coordination in long-term primary care relationships and from specialized services intermittently or through a specific care episode. Registered Nurses (RN) provide much of moderate care coordination. Moderate care coordination improves preventive and chronic disease outcomes, and patient safety and engagement. Complex care coordination provides bio-psychosocial and rehabilitative services for a smaller set of patients with multiple medical, mental health, and social issues complicating the delivery of care. This complex care coordination is often done by a social worker or RN with advanced training and certification in case management. It significantly results in an improvement in outcomes and the reduction of unplanned care, missed opportunity, duplication of services, over all costs for the highest risk cohort of patients. In this presentation we will provide an in-depth discussion of the model and an overview of the steps required to replicate it. The levels of the care coordination framework adheres to the CMSA Standards of Practice of Client Assessment and Resource Management and Stewardship.


1. Describe a levels of care coordination framework and specifically how case management services are integrated into the care coordination stratification

2. Review organizational definitions, business rules, and resource planning that support each level of care coordination: basic, moderate and complex

3. Describe types of patient risk and complexity as well as clinical management and documentation tools, which support care coordination along the continuum