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Redesigning the Health System / Increasing Coordinated Outpatient Care

Increasing Coordinated Outpatient Care2025-11-19T13:21:49-08:00

Coordinating care improves health outcomes while controlling costs1

Coordinated care is an important component of quality, patient-centered care. Care coordination happens when providers listen to patients, take the prior and current care patients receive from other practitioners into account, and administer individualized care from an informed perspective. Coordination of care reduces the risk of medication errors or adverse events.2 Moving the system toward integrated and coordinated care allows patients to receive care in the most appropriate setting, reduces duplication, and enhances quality.3

This indicator tracks the percentage of adult patients whose doctors’ office helps coordinate outpatient care with other providers and services.

Coordinated Outpatient Care

In 2021 (baseline year), 63.5% of patients had a doctor’s office who helped coordinate care with other providers and services. The most recent data available show 63.5% (2021). We hope to reach a target of 72.3% or higher by 2034.

More Data about Coordinated Outpatient Care

Baseline

63.5%

Current Rate

63.5%

Target

72.3%

Indicator Highlights

Gaps in care coordination are linked to a higher risk of preventable adverse health outcomes.4

Chronically ill patients who do not receive coordinated outpatient care experience lower quality care and have higher health care costs.5

Improved electronic health record standardization and interoperability may promote outpatient care coordination.6

Implementation of efficient and effective communication strategies between providers can improve care coordination.7

Data Snapshot

People who did not complete high school are less likely to be asked by doctors about prescriptions and treatment received from other providers than people with some college education.2

Health providers in rural areas face barriers that make care coordination more difficult, such as limited electronic health record sharing and transportation challenges.8

The percent of Californians receiving coordinated outpatient care has steadily increased since 2015, with a slight decrease in 2021.

Percentage of Adults Receiving Coordinated Outpatient Care, Over Time

 

Visualization Help

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Indicator: Percentage of adults who receive Coordinated Outpatient Care, California

Indicator Description: Percent of patients whose doctor’s office helps coordinate their care with other providers or services (Subcategory Adult HMO). Coordinated outpatient care is based on a composite score of responses to Patient Assessment Survey (PAS) questions regarding the provider knows important medical history, followed up on test results, discussed prescription medications, and was informed about care received from specialists. The data reflect patients’ self-reported responses to survey questions.

Data Limitations: Patient data is limited to patients receiving care from medical groups who participate in the Patient Assessment Survey (PAS).

Indicator Source: Integrated Healthcare Association, California Pay for Performance Program (P4P), Measurement Year P4P Manual; National Committee for Quality Assurance; California Healthcare Performance Information System (CHPI), Patient Assessment Survey (PAS)

Indicator Calculation Methodology: Composite is an average of the individual item proportions. Individual items are “Top Box” scores. For Coordinated Care questions, the “Top Box” proportion reflects the number of patients who responded “always” to survey questions about outpatient care coordination (PAS questions 16, 20, 25, & 27), relative to the total responses.

Data Collection Methodology: California survey conducted by mail, online, and phone survey methods. Survey samples are drawn from patient populations in participating medical groups.

Program URL Link: https://www.pbgh.org/program/patient-assessment-survey/

Reporting Cycle: Annually (July)

1. Berkowitz, S. A., Parashuram, S. & Rowan, K. (2018). Association of a care coordination model with health care costs and utilization: The Johns Hopkins Community Health Partnership (J-CHiP). JAMA Netw Open, 1(7), e184273. https://doi.org/10.1001/jamanetworkopen.2018.4273

2. Agency for Healthcare Research and Quality. (2015). 2014 National Healthcare Quality and Disparities Report chartbook on care coordination. AHRQ Pub. No. 15-0007050EF. https://www.ncbi.nlm.nih.gov/books/NBK581138/

3. Let’s Get Healthy California Task Force. (2012, December). Let’s Get Healthy California Task Force Final Report. Let’s Get Healthy California Task Force. https://letsgethealthy.ca.gov/wp-content/uploads/2019/02/Lets-Get-Healthy-California-Task-Force-Final-Report.pdf

4. Kern, L. M., Reshetnyak, E., Colantonio, L. D., Muntner, P. M., Rhodes, J. D., Casalino, L. P., Rajan, M., Pesko, M., Pinheiro, L. C., & Safford, M. M. (2020). Association between patients’ self-reported gaps in care coordination and preventable adverse outcomes: a cross-sectional survey. Journal of General Internal Medicine, 35, 3517-3524. doi:10.1007/s11606-020-06047-y

5. Frandsen, B. R., Joynt, K. E., Rebitzer, J. B., & Jha, A. K. (2015). Care fragmentation, quality, and costs among chronically ill patients. Am J Manag Care, 21(5), 355-362. https://www.ajmc.com/view/care-fragmentation-quality-costs-among-chronically-ill-patients

6. Graetz, I., Reed, M. E., Shortell, S. M., Rundall, T. G., Bellows, J., Hsu, J. (2014). The next steps towards making use meaningful: Electronic information exchange and care coordination across clinicians and delivery sites. Med Care, 52(12), 1037-1041. https://doi.org/10.1097/mlr.0000000000000245

7. Shannon, D. (2012). Effective physician-to-physician communication: An essential ingredient for care coordination. Physician Executive, 38(1), 16-21.

8. Gill, E., Dykes, P. C., Rudin, R. S., Storm, M., McGrath, K., & Bates, D. W. (2020). Technology facilitated care coordination in rural areas: What is needed? Int J Med Inform, 137, 104102. https://doi.org/10.1016/j.ijmedinf.2020.104102

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