Paving the Path to Value: Care Management and Coordination


Supplement sponsor: American Academy of Family Physicians

Fam Pract Manag. 2021 Mar-Apr;28(2):21-25.

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The goal of care management and coordination is to individualize health care to meet each patient’s specific needs. Health care systems that are patient centric, outcome driven, and include payment structures that support services which patients need will be better aligned to meet this goal. In the current fee-for-service (FFS) health landscape, this alignment is often difficult to accomplish, as outcomes are based on how care is incentivized. But the landscape is changing.

Care Management and Coordination in VBP

Cost and patient outcomes are closely tied to effective care management and coordination in VBP arrangements with all payers. Depending on your practice’s specific payment arrangements and the needs of your patient population, the following core concepts can lead to better health outcomes for your patients and improve performance in your VBP contracts.

Patient education – Providing patients with education to help manage their chronic conditions is an essential care management activity. It may include providing patients with health tracking instruments and reviewing results with them; holding classes to help them manage chronic conditions; and offering education and referring patients to community resources. For example, your practice might host monthly diabetes group visits to improve A1C. The frequent touches and support from these group visits can lead to better health outcomes for patients with type 2 diabetes and help the practice meet quality measure requirements.

Care planning – Care plans are an opportunity to better align health care goals with patient and caregiver preferences. They are essential to care management — particularly for patients with multiple complex chronic conditions. Thorough care planning involves patients, caregivers, and the care team developing goals and action steps together; sharing the care plan with patients and all caregivers; and regularly reviewing and updating the care plan to determine if


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