What Is Coordinated Care?

How does a coordinated care approach work?

When a team of health care providers uses a coordinated care approach, they work together to organize a patient’s health care plan to achieve the best possible outcomes.

The patient is actively engaged in their own care, and all team members understand the patient’s unique needs and preferences. The team clearly communicates with the patient, and each other, to ensure they deliver personalized care and support. Coordinated care is important for all patients, but it’s especially important for patients who may be managing multiple health conditions.

Most patients have a primary care provider (PCP) who’s cared for them over a long period of time. They are familiar with the patient’s health history, perform routine health screenings and help them manage common health conditions. Primary care providers refer patients to a specialist if the patient needs a diagnosis or special care for a more complex health condition like heart disease, cancer, or a behavioral health condition.

Coordination of care can help ensure a patient gets individualized and efficient treatment and support at each step in their journey. Each health care provider:

• Understands the patient’s medical history, current needs, and health goals 
• Delivers the appropriate care at the right place and time
• Shares knowledge among the team to ensure everyone involved in the patient’s care is up to date on changes in the patient’s health, new bloodwork, imaging, medication, etc. 
• Participates in developing a holistic care plan to optimize the patient’s health outcomes 
• Monitors the patient’s progress and works with other providers to adjust the care plan as needed
• Addresses the patient’s questions and concerns

What are the advantages of coordinated care?

Advantages of coordinated care include:

• Patients are empowered to be active members of their health care team.
• Health care providers foster strong relationships with patients and each other to ensure everyone understands the health care plan and goals.
• PCPs provide seamless referrals to trusted specialists for timely diagnosis and advanced treatment options.
• PCPs coordinate with specialists to help patients manage chronic conditions, such as diabetes or high blood pressure.
• Providers are familiar with a patient’s medical history and proactively alert the care team to changes in a patient’s needs or care plan.
• Patient navigators schedule appointments and testing so that patients can get coordinated checkups, imaging and lab work in a convenient location.
• Team members connect patients to helpful resources including interpreter services, technology resources and support, financial assistance, community services, etc.
• Patients have optimal health care experiences due to proactive, clear communication across the team.

Integrated Care: Convenient, coordinated care

Mass General Brigham Integrated Care is one approach to coordinated care that provides high-quality, collaborative care. Our providers and staff work together for you and with you as your partners in health to help you get the care you need. We bring the best of care closer to you and connect you to total health.

“We want to get to know our patients as whole human beings and we really want to build a relationship with patients,” explains Vice President of Operations Development, Lindsay Gainer, RN, MSN. “We believe that through care centered around relationships, we can best help people to health and wellness. We don't want to just treat problems. We want people to be healthy and we believe that relationships with your physicians and the entire team are so important. We want people to have comfort and familiarity when they when they interact with our team.”

“Many of our patients drive downtown to Boston for care because they don’t have an offering near them,” adds Gainer. “Our locations in Watertown, Burlington, and soon in Salem, NH provide that same comprehensive care closer to home. Our hope is that these Integrated Care locations become familiar health destinations and an important part of these communities.”

Integrated Care services and offerings include: 

• Primary care
• Behavioral health
• Imaging
• Outpatient surgery
• Specialty care

“We also want to ensure that patients can access care conveniently and at times that work for their schedule,” Gainer says. “We can deliver virtual care or in-person care close to home when needed, and because we are part of Mass General Brigham, we can also connect patients to hospital care when they need it.”

With Integrated Care, you have access to multiple health care services in one convenient location with a centralized medical record and patient navigators who help coordinate the day-to-day details of your care. Learn more about the advantages of Integrated Care.