blog Post
Care Coordination
Care Coordination
For ACOs
Coordinate care across providers, close gaps, and ensure timely, effective interventions.
For ACOs operating under shared savings and quality benchmarks, care coordination is essential to improving performance. It connects population health insight to action by helping teams manage care across providers and settings. But fragmented data and disconnected workflows can make it difficult to prioritize outreach, align on next steps, and follow through consistently. Koan Health helps turn insight into coordinated, data-driven action.
What Is Care Coordination?
Care coordination is the process of organizing patient care activities across providers, settings, and time so patients receive appropriate, timely, and effective care.
For ACOs and value-based care organizations, care coordination includes identifying patients who need intervention, addressing care gaps, and ensuring follow-through on care plans. In day-to-day operations, it means making sure the right follow-up happens after a hospitalization, specialist visit, or other key transition in care.
Why Care Coordination Breaks Down in Practice
Care coordination often breaks down at the point of execution. Care teams may know which patients need attention, but without shared visibility and clear workflows, outreach is delayed, follow-up is inconsistent, and tasks fall through the cracks. Disconnected systems and manual processes make it harder to coordinate across providers and act at scale.
Many organizations also lack visibility into whether interventions were completed or effective. That leaves care coordination incomplete and creates missed opportunities to improve outcomes and performance in value-based care.
What You Can Do with
Care Coordination
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Identify patients who need intervention sooner
Recognize which patients need attention based on care needs, risk, and utilization patterns—particularly high-risk patients with chronic conditions—so care teams can act earlier and more effectively.
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Prioritize outreach and care management efforts
Focus care coordinators on the patients, conditions, and transitions that require the most immediate follow-up, helping teams use time and resources more strategically.
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Improve coordination across providers and settings
Strengthen alignment across primary care, specialists, and care teams so patients experience more connected, consistent care throughout their journey.
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Support gap closure and quality improvement
Address care gaps more proactively and support quality improvement initiatives with a clearer view of where intervention is needed most, aligned with quality measures reporting.
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Track progress and improve care coordination performance
Monitor care coordination efforts over time to understand what is working, where follow-up is needed, connecting to broader financial analytics.
How Koan Health Enables
Care Coordination
Koan Health combines analytics, workflow automation, and real-time visibility to help care teams coordinate more effectively across providers and settings. By connecting patient insight to actionable workflows, the platform helps organizations prioritize interventions, improve follow-through, and track care coordination efforts with greater consistency and accountability.
Patient Cohort
Identification
Segment patients using integrated clinical, claims, and risk data—built on Koan Health’s population health analytics foundation— to prioritize those who need intervention most.
Result: Faster, more targeted outreach
Workflow
Automation
Automate care coordination workflows to reduce manual effort and ensure timely, consistent follow-up across care teams.
Result: Greater efficiency and fewer missed interventions.
Real-Time
Patient Tracking
Track patient activity and care coordination efforts at the individual level with a shared, up-to-date view across providers.
Result: Better alignment and continuity of care.
Provider
Engagement
Deliver actionable, patient-level insights that help providers focus on the right patients, conditions, and key care transitions.
Result: More effective engagement and improved care continuity
Closed-Loop
Performance Tracking
Monitor care coordination activities from identification through intervention and outcome. Use that visibility to refine care management over time.
Result: Improved accountability and stronger performance
Why Koan Health Is Different
Insight to Action—Without Fragmentation
Koan Health connects analytics directly to care coordination workflows, helping reduce the gap between insight and execution.
Result: Faster action and more consistent gap closure.
Unified Data Foundation
Aggregate clinical, claims, and third-party data into a single, source of truth for care coordination.
Result: Better decisions and improved alignment across teams.
Designed for Care Team Workflows
Support real-world care coordination processes with intuitive tools for prioritization, task management, and follow-up.
Result: Increased efficiency and reduced administrative burden.
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Closed-Loop Visibility
Track care coordination activities end-to-end, from patient identification to completed interventions and outcomes.
Result: Continuous improvement and stronger value-based performance.
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Partnering with Koan Health transformed our care coordination processes. The integration and actionable data they provided have streamlined our workflows and empowered our providers to deliver more targeted patient care across our programs.Vice President, Clinical InformaticsRegional ACO
Frequently Asked Questions For Care Coordination
What is care coordination in healthcare?
Care coordination is the process of organizing patient care activities across providers, settings, and time to ensure patients receive appropriate, timely, and effective care. It helps align care teams, reduce gaps, and improve the overall patient experience.
How does care coordination improve patient outcomes?
Care coordination improves patient outcomes by ensuring that care is connected across providers, reducing gaps, duplication, and delays. It supports timely interventions, better communication, and more consistent follow-up.
How is care coordination used in value-based care programs?
In value-based care, care coordination helps ACOs align care teams, improve quality performance, and reduce unnecessary utilization. It supports better outcomes while helping meet cost and quality benchmarks.
What are the best practices for effective care coordination?
Best practices include identifying high-risk patients early, aligning care teams around shared workflows, ensuring timely communication across providers, and tracking whether interventions are completed. Continuous monitoring and refinement are important for sustained performance.
What challenges do organizations face with care coordination?
Common challenges include fragmented data, disconnected systems, and limited visibility into whether interventions were completed. These issues can lead to missed care gaps, inconsistent follow-up, and reduced effectiveness of care coordination efforts.
What technology do ACOs use to support care coordination?
ACOs typically use platforms that integrate clinical, claims, and operational data into a unified view of patient activity. These tools help identify patients who need intervention, prioritize outreach, track efforts, and monitor outcomes over time.
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Turn Care Coordination Into Measurable Performance
Koan Health helps ACOs connect insight to action so teams can prioritize patients, close care gaps, and improve outcomes with confidence.
