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What is Care Coordination?

Care coordination improves quality of life and satisfaction for patients and families as well as the satisfaction of the teams who serve them.

It manages health care costs by using a proactive rather than reactive approach to care.

It allows the primary care team to anticipate health care needs and reduce burdens on acute care settings.

Care coordination organizes the individual patient's care and facilitates the sharing of information across a patient's whole health care team.

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Chronic care management within an advanced patient-centered medical home

The medical home is not a place, but instead a model of providing primary care. In a medical home, care is coordinated between preventative care, chronic care, and acute needs. A medical home is accessible, compassionate, family centered, patient, comprehensive, appropriate, coordinated and continuous. 

The advanced medical home encompasses all of the above, but also incorporates an innovative care team and practice operations approach to identify those with high health risks and help them reach their healthcare goals.  IC4’s coached team based structure embodies this approach.

Physician champions facilitate the work of the nurse care coordinator within a practice by serving as an advocate for best practices and cheerleading other participating clinicians within the practice.

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Within the framework of the medical home, IC4 practices ensure seamless delivery of care by

  • Having the same primary care team provide services longitudinally
  • Seeing patients more frequently for chronic care visits (2-4 times per year instead of annually)
  • Allotting longer or more comprehensive visits for patients with complex needs through the assistance of the care coordinator
  • Having direct access to expertise on community and governmental resources that address the comprehensive services needs of patients
  • Arranging for a safe transition of care when needed
  • Sharing decision making for health care goals between patients and caregivers

Providing chronic care management within the medical home framework requires a deeper understanding of the life course of patients and the statewide resources available to support them. 

ICCCC primary care practices engage in a learning collaborative together with other practices to share and enhance their skills in caring for patients with medical complexity.  Learning collaborative topics include delivery of:

  • a medical home
  • chronic care management
  • collaboration with schools and community resources
  • safe transitions of care

The learning collaborative provides Continuing Medical Education credits through the Indiana University School of Medicine Division of Continuing Medical Education and Part IV Maintenance of Certification credit through the Department of Pediatrics American Board of Pediatrics portfolio committee.

Shared Plans of Care

A Shared Plan of Care, or SPOC, is a living document developed by a care coordinator in partnership with the patient and their primary care provider. SPOCs have three components:

  1. Introduction to patient and family
  2. Medical summary
  3. Goals and negotiated actions

The SPOC is created by 1) a structured interview between the care coordinator and the patient and family, 2) a summarized review of the medical records, and 3) a collaboration between the principal care team and the family to consider goals and the necessary actions to achieve those goals.

Getting to know the patient and family

Health care is about people. It is personal. Building an understanding of the patient and family is important to shaping the care to fit the family.

In addition, where people are born, live, learn, work, play, worship and age has a significant impact on health and quality-of-life outcomes. These social determinants of health are important to the coordination of care.

The portable medical summary

This information serves as a snapshot of the patient’s current state.  Collecting accurate information about the patient’s complex health needs makes it easier for everyone to have a shared approach to care. The SPOC summarizes chronic conditions, medications, treatments, equipment, subspecialists, procedures, and service providers.

graphic of woman sitting in a chair talking to a small girl

Goals and actions

Patients and families who deal with medical complexity often describe themselves as “in survival mode.”  Families say that this can make it hard for them to imagine the future.  Proactive care coordination works to build strong relationships at the start. It starts with a question like “What is your priority of what you most need right now to help you?”  It works to create a view of the “whole person” to help families move towards developing a long-range vision for health and wellness, in addition to helping with the days that feel chaotic.

Using a structured and comprehensive intake interview can help families identify needs that they did not even realize they had. Care coordination shifts families and their healthcare team from a mindset of “putting out fires” to anticipating needs and helping patients flourish in their best lives.

Sharing SPOCs

  • SPOCs are regularly updated- at least every 6 months and when new health events occur that change the plan.
  • Families are encouraged to keep a copy of the SPOC available to share any time they need to tell their story, for example at an emergency room visit.
  • SPOCs are used at primary care visits to help the team provide satisfying chronic care management for each patient and family based on their shared needs and priorities.
  • SPOCs can be shared across the care neighborhood, with specialists, home care agencies, school nurses, and any other service providers who would be able to better serve the family with its summarized communication of important information.

Contact Information

Contact us for more information about the Indiana Complex Care Coordination Collaborative.

Contact Us


Looking for patient care? Pediatric primary care can be reached at the site below.

Riley Primary Care