Care Coordination

Care coordination is emerging at the forefront of conversations about health care and human services innovation. As the health care system has become more advanced and the needs of individuals have become more diverse, medical and human services communities are moving toward an increased annexation of social determinants of health (SDoH) into primary care. This has led to a wider need for care coordination among human services providers, especially for individuals with complex health histories.


SDoH are the non-medical factors that impact a person's health, such as their socio-economic status, education, and access to healthy food and safe housing. Factors such as poverty, lack of education, and inadequate housing and nutrition are often linked to poor health outcomes. By addressing these SDoH, care coordination can help vulnerable populations achieve better health outcomes. To tackle these issues, behavioral and physical health providers use care coordination to help their clients lead a full, stable, and successful life.

Table of Contents

What Is Care Coordination?

According to the Department of Health and Human Services, care coordination is the deliberate organizing of client activities among multiple participants to support and facilitate services that are appropriate, safe, and effective. Participants would include other organizations, the client, and partners and would require information sharing for the client’s benefit. Coordination is a crucial aspect of health care that can improve client outcomes and reduce health care costs.

In the past, an individual’s records were documented in separate systems for each provider, resulting in unnecessary revisits to the health care system and inefficient use of time and money for the client, their case manager, and their doctors. Nowadays, care coordination software that’s connected to the appropriate managed care organization, regional health information organization, or health information exchange (HIE) is used to communicate information securely between them.

This integration gives each provider a full view of the client’s health history, facilitating the best possible care for each of the individual’s concerns, including the necessary follow-up, support, and reminders to keep them on the right path. This coordinated care allows people to live the most healthy and productive lives possible, particularly those with complex health histories and vulnerable populations, such as elderly people, those with disabilities, and those living in poverty.

The Importance of Information Sharing Among Stakeholders

Software and technology have revolutionized care coordination by facilitating information sharing, effective communication, and coordinated care among health care and human service providers. Electronic health records, telemedicine, and other digital tools enable seamless access to care, benefiting individuals in remote areas or with mobility challenges. Leveraging technology enhances care quality, efficiency, and cost reduction, especially for vulnerable populations. Coordinated care ensures timely and personalized support, which is crucial for providers reliant on government funding, Medicare, and Medicaid, as it optimizes revenue streams and reporting.

Fast Healthcare Interoperability Standards (FHIR)

The 21st Century Cures Act mandates the use of Fast Healthcare Interoperability Standards (FHIR) in modern care coordination software, facilitating secure sharing of patient health information and interoperability. FHIR acts as a common language that bridges gaps in fragmented health care and human service systems, promoting care coordination and comprehensive data exchange. It enables messaging between various providers, such as mental health, primary care, and housing. FHIR also aligns with HIPAA regulations, ensuring compliance and protecting patient data. By leveraging FHIR, developers can create software solutions that securely transfer patient data between different healthcare systems, reducing privacy risks and legal issues.

One of the primary reasons for the importance of FHIR in care coordination software is its emphasis on data security. FHIR provides a standardized framework for exchanging health care data in a secure and reliable manner. It incorporates various security features, such as authentication, authorization, and encryption, to safeguard patient information from unauthorized access or breaches. By adhering to FHIR standards, care coordination software developers can ensure that patient data remains protected throughout its lifecycle, including transmission, storage, and access.

Information Blocking

By adopting FHIR standards, care coordination software can aggregate and harmonize patient data from multiple sources, including electronic health records, laboratories, pharmacies, and wearable devices. However, interoperability and information blocking are distinct yet closely related concepts in health care data exchange. Interoperability refers to seamless communication and exchange of electronic health information between different systems. Information blocking refers to practices that hinder or prevent such data sharing. Overall, the Cures Act recognizes that blocking the flow of electronic health information can impede care coordination, patient engagement, and hinder health care advancements so it discourages practices that restrict information sharing.

By emphasizing the importance of information sharing, this recent legislation aims to enhance the quality of care, patient outcomes, and health care innovation through data-driven insights. It encourages the adoption of interoperability standards and practices, fostering a more connected and efficient health care system. This comprehensive view of patient health information empowers health care providers to make informed decisions, improve care coordination, and enhance patient outcomes.

Care Coordination, Care Management, and Case Management

“Care coordination,” “care management,” and “case management” are often used interchangeably. While they are related and are all important components of health care, they are not the same thing. Understanding the differences between care coordination and care management can help providers choose the right tools and strategies to improve individual outcomes. By working together, health care providers can ensure that people receive the right care at the right time, while also addressing wider population health issues. Here are some key nuances among the three terms:

Care Coordination

Care coordination takes a broader, population-based lens regarding health care. It involves a wraparound, longitudinal approach to client care, often considering the individual’s SDoH and aiming to provide seamless communication among multiple providers and other players such as community-based organizations. For example, it may involve systems such as behavioral health, mental health, or home health alongside primary care, housing, employment specialists, and hospitals. It often even extends to the peron’s pharmacy or family.

The main goal of care coordination is to meet individuals’ needs and preferences in the delivery of high-quality, high-value health care. Achieving this goal involves bringing together different health care providers and community resources to ensure that people receive the right care at the right time. Care coordination can address a wide range of issues, including SDoH and value-based care. Value-based care is an approach that focuses on delivering quality over quantity, or value over volume.

Care Management

Care management is focused on individuals with immediate or acute needs. While care coordination is a population-based approach, care management has a narrower focus that is intended to address the most time-sensitive needs of each person. It often involves managing specific health conditions or situations for individuals. Care management requires a clinical lens when managing a client’s care, often focused on short-term interventions and crisis care for acute illnesses or flare-ups of chronic conditions.

For example, a person with diabetes may require care management to help them maintain their blood sugar levels, monitor their medication, and make lifestyle changes. Care management can also be used to help people transition from the hospital to home, manage chronic conditions, and navigate complex health care systems.

Case Management

While both care coordination and care management are essential components of value-based care arrangements, they differ from case management in their scope and approach to individual care. Case management is a holistic approach that centers on addressing every aspect of recovery. With a view toward the overall rehabilitation process, a case manager helps the client navigate each hurdle individually.

While care coordination implies collaboration among many stakeholders, a case manager typically focuses on working directly with the client to manage their interactions with and among the various systems. They provide continuous support toward recovery, including administrative assistance in finance, legal matters, medical assistance, education, housing, food security, and returning to work.

How Care Coordination Supports Health Care Equity

Health care equity is the fair and just distribution of health care resources and services to all individuals, regardless of their socioeconomic status, race, ethnicity, or other factors. Unfortunately, there are significant disparities in access to health care and health outcomes for vulnerable populations, including those with behavioral health conditions and developmental disabilities as well as those experiencing homelessness. Care coordination can play a critical role in addressing these disparities and promoting health care equity. Here’s how:

Behavioral Health, Mental Health, and Substance Abuse

According to a report by the National Institute of Health, care coordination can help address the complex needs of individuals with behavioral health conditions by ensuring that they receive appropriate treatment and support from multiple providers, including primary care physicians, psychiatrists, and social workers. It is becoming increasingly evident that mental, physical, emotional, intellectual, social, spiritual, environmental, and financial health are interrelated and lead to behavioral continuity, well-being, and overall thriving. According to the Substance Abuse and Mental Health Services Administration, these factors are known as the eight dimensions of wellness.

So, when an individual experiences a deficit, delay, setback, temporary condition, or chronic illness in any area, it is more likely that other co-occurring issues or illnesses may arise. Care coordination can improve health outcomes across the domains. However, a lack of communication and collaboration among providers in different health care systems, along with legal and organizational barriers to sharing information, poses significant challenges to implementation.

The creation of effective linkages between mental health providers, substance-use disorder treatment providers, general health care providers, and other human service agencies is recommended, along with complementary actions from government agencies, technology developers, and funders. Care coordination models and the software that facilitates them are critical for the delivery of integrated care. They enable equitable outcomes for individuals entering the ecosystem outside the traditional medical and primary care touch points.

Focus on Empowering People With Developmental Disabilities

Care coordination can also help individuals with developmental disabilities access necessary services and support, such as specialized medical care, assistive technology, and behavioral therapies. Individuals with developmental disabilities often require community-based support that falls outside the primary care model. Some unique differences, however, are that these people:

  • May have less capacity to advocate for themselves.
  • Generally have longer or lifetime periods of involvement with the health and human service system.
  • Require support from providers with significantly more credentials or experience working with their specific disability.
  • Can benefit greatly from assistive technologies that are expensive, hard to come by, require a referral from a primary care physician, or are contingent on rare insurance pre-approvals.

Special Consideration for Clients Experiencing Homelessness

Care coordination is also essential for addressing the complex needs of individuals experiencing homelessness. According to a report by the National Health Care for the Homeless Council, individuals experiencing homelessness are more likely to have chronic health conditions and to face barriers to accessing health care such as:

  • Lack of identification documents or health records.
  • Poor hygiene, which can lead to being turned away by service providers.
  • Inability to receive appointment notifications, follow-up reminders, and other updates because of limited access to the internet, email, or a smartphone.
  • Lack of access to affordable transportation or childcare to attend appointments.
  • Stigma from the community regarding the likelihood that they can pay for services, even if they have access to social benefits or cash to do so.
  • Discrimination from primary care providers who accept state-sponsored Medicaid, federal Medicare, private insurance, and fee-for-service because the payouts are generally higher from private payers.
  • Co-morbid physical, mental health, and substance abuse conditions that are challenging to treat without a stable home.

Care coordination can help ensure that individuals experiencing homelessness receive timely and appropriate care for any conditions they have, as well as support for other needs, such as assistance with housing options, skill-building opportunities, legal resources, and employment assistance.

Care Coordination Software

Care coordination software, like Foothold Care Management (FCM), can facilitate information sharing and collaboration among providers, streamline workflows and processes, and support the goals of care coordination. According to the American Academy of Family Physicians, chronic care management involves the provision of comprehensive and coordinated care to individuals with chronic illnesses to enhance their well-being and reduce health care costs. Here are some examples of how care coordination software can make care management more comprehensive:

  • Facilitates information sharing among health care providers.
  • Streamlines workflows and processes to support care coordination goals.
  • Establishes accountability among care team members.
  • Assists with care transitions and ensures continuity of care.
  • Supports people’s self-management goals.
  • Tracks client services and supports clinical workflow.
  • Automates clinical tasks, including care plan creation and CPT code assignments.
  • Provides analytics to interpret client data and identify health trends.
  • Measures staff performance and addresses workflow inefficiencies.
  • Organizes care activities among different services and providers.

Care coordination software can also reduce health care costs. Collaboration with specialists, behavioral and mental health care providers, social and community services, pharmacies, and retail clinics or urgent care providers is essential for understanding a person’s entire health care tapestry. When all stakeholders understand an individual’s needs, they are empowered to identify high-risk individuals much earlier and prevent avoidable hospitalizations. They can also prevent the duplication of services that won’t be reimbursed by the insurance company, and they can avoid spending excessive time completing medical history intakes and follow-ups by referring to real-time data from the person’s other doctors.

Key Functionalities of Care Coordination Software

As health care continues to evolve, care coordination software has become increasingly important for providers, as it enables seamless health care delivery by connecting all those involved in the client’s care. This high granularity of information sharing on the person’s history, appointments, and details of their future care plan empowers health care providers to meet the needs of their clients more effectively, improve individual outcomes, and become more efficient at teamwork. Here are some key functionalities of care coordination software:

Patient Cohort Management

Care coordination is a crucial aspect of population health management, which aims to improve the health outcomes of an entire population. Care coordination software helps identify populations with specific disease management needs, such as those with chronic conditions or those at risk of readmission. By identifying these individuals and providing targeted care, health care providers can better tailor their crisis response systems, serving high-risk clients better and reducing costs for both individuals and providers.

Evidence-Based Content Libraries

Care coordination software often includes curated clinical content libraries that follow guidelines and best practices. These content libraries are based on validated clinical research and decision-support tools that help health care providers make informed decisions about client care. By providing evidence-based content, care coordination software ensures that people receive the best possible care.

Referral Management

Collaboration among primary care providers, specialists, hospitals, and other providers is essential for effective care coordination. Care coordination software helps manage referrals for appropriate care settings and cost savings. For example, if a person needs to see a specialist, care coordination software can help identify the most appropriate specialist for that person’s needs and facilitate the referral process, including which specialist accepts their private insurance or is in-network with their Health Maintenance Organization. This ensures that people receive timely and appropriate care, while also reducing costs.

Support for Community-Based Resources

Besides medical care, people often need access to community-based resources to meet their socioeconomic needs. Care coordination software can refer individuals to organizations such as transportation, local government agencies, public health resources, and social programs. By integrating information about these resources into the care coordination software, health care providers can ensure that their clients receive holistic care that addresses all of their needs.

Care Coordination Software and EHRs

Care coordination software and EHRs play a vital role in delivering quality care to clients. While both systems collect demographic and medical data, there are distinct differences in their roles and functionalities. The primary distinction between the two system types is the intended end-use case:


EHRs are primarily client-centric, serving as a digital version of traditional paper records that contain information such as medical history, medication lists, and lab results. EHRs serve as a central repository of individual information that can be accessed by health care providers, ensuring that treatment decisions are based on accurate and up-to-date information. They essentially provide the foundation for individual data management.

Care Coordination Software

Conversely, care coordination software provides a care manager–centric view, enabling health care providers to access and share client information for seamless delivery. This helps them manage individual care by providing necessary information to the care team, streamlining communication and collaboration among health care providers.

The Future of Care Coordination Software

EHRs and care coordination software play complementary roles in enabling proper and quality care for clients by providing a comprehensive view of all data. For instance, EHRs can help staff identify people who need follow-up appointments to discuss lab results, referrals, or medication refills. Additionally, EHRs can provide a complete record of a person's medical history. Here are some examples of interoperability features offered to providers that are a part of the Foothold Technology Community:

  • E-labs and E-prescriptions.
  • Access to the HIE.
  • Direct messages among providers.
  • Critical alerts on client activity such as emergency room admission.
  • Data reports that contribute to wider population-level research.

However, it's worthwhile to consider that even a focus on more robust interoperability between EHRs and care coordination software doesn't provide the full picture of what's possible. Before imagining the future of an integrated health care system, consider some of the challenges and barriers:

  • Insurance reimbursement procedures and other financial mechanisms don't currently support the level of teamwork and collaboration within their billing and coding that occurs with care coordination.
  • Primary care doctors, behavioral health providers, and other specialists are often not located in the same physical offices.
  • Primary care doctors are not well trained on holistic intake and treatment plans while referrals remain the norm.
  • Privacy regulations at either the administrative or policy level may hinder the seamless integration of EHRs and care coordination software.
  • Service providers in an overburdened system may not have the motivation to innovate or adopt more collaborative systems without substantial training and support and/or clear financial incentives or rewards.

There is a growing understanding that technology can play a major role in breaking down some of these barriers. Tools like video communication, automation, screen sharing, 3D modeling, and more can be woven into EHR and care coordination programs to enhance the provision of services. At the same time, health care policy advocates and app developers require continued promotion at the policy level and cross-industry collaboration with financial systems, including decentralized options, to adopt the most significant innovations in a way that offers benefits instead of an additional burden.

Implementing Care Coordination Software: Best Practices

Implementing care coordination software can be a complex process, but following best practices can ensure a successful implementation.  Care coordination promotes real-time communication among health care providers and other stakeholders such as community-based organizations and social service agencies. According to a report by the Journal of Population Health Management, care coordination can help facilitate communication and information sharing among providers and stakeholders, leading to improved client outcomes and more efficient service delivery. It also addresses issues of urgent care versus longitudinal care, acute episodic treatment versus chronic pain management, and high risk–prevention management.

Care coordination can also streamline service delivery and reduce health care costs. According to a report by the Agency for Health Care Research and Quality, care coordination can help reduce duplication of services, improve the use of health care resources, and decrease costs overall. By integrating EHRs into care coordination software, multiple staff across various teams can track a person’s progress and communicate with one another to ensure that all aspects of that person’s care are being addressed.

With the rapid research and development of software solutions and technologies, organizations should remain informed and adapt to the ever-evolving landscape of care coordination technology. Ongoing advancements in this field offer tremendous potential to further enhance the delivery of health and human services. By following best practices, joining a community of like-minded organizations like Foothold Technology, and continuously monitoring and evaluating the software’s effectiveness, you can feel confident about having a successful implementation of care coordination software and seeing the results in your client outcomes and financial balance sheets.

Care coordination software enables you to contribute to the overall healthcare system while providing more holistic, person-centered care.