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Chronic disease care coordination requires partnership between payers and providers. It brings healthcare and health insurance professionals back to the fundamentals like addressing social determinants of health and improving data transfers.

Care management. Medication management. Health information technology. Patient-centered medical home.

A diagram of the Population Care Coordination Process outlines the six step of the process. These steps include data analysis, selection, assessment, planning, interventions and monitoring. These steps are completed at the population and individual levels.

Successful care coordination requires several elements: Easy access to a range of health care services and providers. Good communications and effective care plan transitions between providers. A focus on the total health care needs of the patient. Clear and simple information that patients can understand.

Examples of specific care coordination activities include: Establishing accountability and agreeing on responsibility. Communicating/sharing knowledge. Helping with transitions of care. Assessing patient needs and goals. Creating a proactive care plan.

To achieve effective patient management, the Chronic Care Model promotes comprehensive system change encompassing six broad areas: health care organization, linkages to community resources, self-management support, delivery system redesign, decision support, and information systems.

To achieve effective patient management, the Chronic Care Model promotes comprehensive system change encompassing six broad areas: health care organization, linkages to community resources, self-management support, delivery system redesign, decision support, and information systems.

Care coordination addresses potential gaps in meeting patients' interrelated medical, social, developmental, behavioral, educational, informal support system, and financial needs in order to achieve optimal health, wellness, or end-of-life outcomes, ing to patient preferences.