Care Coordination: What It Is and What to Expect
Medically reviewed by Sumiran Racherla, MD, Internal Medicine. Last reviewed: October 23, 2026.
What kind of doctor provides Care Coordination?
A primary care doctor, a doctor who handles your everyday health care, takes part in care coordination. The primary care doctor works with specialists, who are doctors trained in one area of medicine, and with the rest of your care team. A direct primary care or concierge doctor can be a first stop for an evaluation and can refer you to a specialist when needed.
What it is
Care coordination means organizing a patient's care across many health care providers. In a primary care practice, the team plans care on purpose. They also share information with everyone who helps care for the patient. The aim is safer and more effective care.
The main goal is to meet each patient's needs and preferences. The care should be high-quality and high-value. Poor coordination is called fragmented care. It happens when providers do not talk well with each other about a patient's care.
Why a doctor might recommend it
Doctors coordinate care so that a patient's needs and preferences are known. These should be shared at the right time with the right people. Care may need coordination at times like these.
- Follow-up care after an emergency hospital visit.
- Care between a primary care provider and several specialists for a chronic (long-lasting) health condition.
- A temporary stay in a skilled nursing facility.
- Work with social services on housing, transportation or food.
How to prepare
Some steps set up the plan for your care. Providers assess your needs and goals. They create a proactive care plan, which is a plan made ahead of time. They also agree on who is responsible for what.
What happens during it
Care coordination can include these activities.
- Sharing knowledge among the people who help with your care.
- Helping with transitions of care, such as the move from hospital to home.
- Monitoring and follow-up. This includes responding to changes in your needs.
- Supporting your self-management goals.
- Linking you to community resources.
Doctors can use the same platform for electronic health records. Then each provider can see and update a patient's medical history.
A CMS example shows how this works. A woman has chest pain and shortness of breath. She is diagnosed with a heart attack in an emergency department. Her test results go into her electronic health record. An alert goes to her primary care doctor. A cardiologist, a heart specialist, reviews the record at her visit. Then her primary care doctor checks the record and checks in with her.
Recovery
Care coordination includes keeping track of how you are doing and following up. This means responding to changes in a patient's needs. Coordinated care can help keep patients healthier longer. It can also help them better manage chronic conditions.
Risks and side effects
Fragmented care can cause problems for patients. Patients can face repeated lab tests. They can get drugs that do not work when taken together. They can make extra trips to the doctor's office that a phone call could have handled.
Poor coordination can also lead to poor health and more use of emergency care. It can lead to medication errors and medical errors. It can also lead to poor transitions of care from hospital to home.
AHRQ also notes that patients are often unclear about why they are referred to a specialist. They may not know how to make appointments or what to do after seeing a specialist.
Who performs it
Doctors and other health care providers work together to coordinate a patient's care. Some providers take part in a program that supports care coordination.
Common questions
Why is care coordination important?
Care coordination is important because it can help keep patients healthier longer. It can also help them better manage chronic conditions.
What happens when care is not coordinated?
When care is not coordinated, treatments from different doctors might conflict or become unmanageable for the patient. The patient is also more likely to get unnecessary repeat tests.
How do doctors share information about a patient?
Doctors can use the same platform for electronic health records, so each provider can see and update a patient's medical history.
How does a direct primary care or concierge doctor fit in?
A direct primary care doctor charges a flat monthly fee instead of billing insurance, while a concierge doctor usually charges more and often works alongside insurance. In primary care, coordination means planning care on purpose and sharing information with everyone involved. In one CMS example, the primary care doctor reviews the medical record after a specialist visit and checks in with the patient.
Sources
- Agency for Healthcare Research and Quality - Care Coordination
- Centers for Medicare & Medicaid Services - Care Coordination
Medical Disclaimer
This content is for general educational and informational purposes only and is not medical advice. It is not a substitute for professional medical advice, diagnosis, or treatment, and reading it does not create a doctor-patient relationship. Always seek the advice of your physician or another qualified health provider with any questions about a medical condition, and never disregard or delay seeking professional advice because of something you read here. If you think you may have a medical emergency, call 911 (or your local emergency number) immediately.
