A System-Wide Care Coordination Council as a Centralized Forum

To unify and align all elements of care coordination, a System-Wide Care Coordination Council was established across a large, multifaceted healthcare. With a significant geographic footprint, this system includes four hospitals and 115 primary care practices across five counties, ranging from urban to rural communities, and serves diverse populations.

Care coordination services span the full continuum of care, including inpatient hospital care coordination, ambulatory care coordination, home care services and additional supportive programs designed to meet the needs of the patient population. Ensuring patients have access to the right level of care — delivered where they are, requires intentional planning, structured communication and collaborative teamwork across all service lines.

To achieve optimal continuity of care, each service line must understand the resources, programs and supports available throughout the system. This shared awareness is cultivated through meaningful communication and interdisciplinary collaboration, strengthening care transitions and promoting seamless handoffs between services. Effective coordination enhances patient support, improves clinical outcomes and contributes to reduced utilization rates. The System-Wide Care Coordination Council convenes monthly and brings together representatives from all service lines involved in patient care coordination. The Council serves as a centralized forum to:

• Identify system-level and geographically specific care coordination challenges
• Address operational gaps and transition barriers
• Develop and implement solutions to improve care continuity
• Standardize best practices across the continuum
• Promote accountability and shared ownership of patient outcomes

Importantly, the Council ensures that all service lines have a voice in evaluating and strengthening access to care and continuity across the system. This session will demonstrate how, through collaborative leadership and coordinated strategy, the Council works to ensure that patients’ health needs are met across the full spectrum of care.