The Agency for Healthcare Research and Quality (AHRQ) found that poor healthcare coordination can increase healthcare costs by up to 20%, often due to redundant tests and unnecessary treatments. Disjointed systems can lead to delays in follow-up care, medication errors, and poorer health outcomes. Studies have even found that most serious medical errors involve miscommunication during care transitions, such as shift change or discharge.
Care coordination is frequently considered in terms of systems, workflows, and communication between providers. But for patients, it’s much simpler: it’s the difference between feeling guided through care and feeling lost within it.
When care coordination works well, patients rarely notice it. When it doesn’t, it is impossible to ignore.
For patients, care coordination starts with clarity. “When a patient comes in, they want to feel like they clearly understand what’s going to happen,” said Jill Hanson, project specialist in the Healthcare Transformation Department at MetaStar.
However, from the care team perspective, coordination often focuses on role and responsibility alignment. “Care coordination among team members provides a high level of understanding of the patient,” Hanson explained. It ensures all care providers are “on the same team and on the same page.”
The goal is to bring the patient and care team perspectives together. When they don’t align, patients can feel lost in a challenging healthcare system.
Good care coordination is easy to overlook because it feels seamless. In inpatient settings, nurse handoffs can demonstrate effective coordination.
“During the shift change, the nurse leaving and the nurse coming on duty would come to the room together and share information. They would ask if there was anything I wanted to add,” said Linda Knight-Rivera*, a patient with a complex, chronic illness. “Talking to me instead of about me was a nice change.” When the patient is involved in the handoff, they become part of the coordination process, not just the subject of it.
Coordination also appears in small but significant ways across settings. Scheduling related appointments together and ensuring seamless transitions transforms what could feel like multiple disconnected visits into a more cohesive experience. Escorting patients between appointments may seem trivial, but it can remove unnecessary navigation, repetition, and stress.
Careful chart review and communication between team members and specialists help patients feel their providers are all on the same team. Automatically scheduling follow-up appointments after a hospitalization and making follow-up calls after surgery or discharge ensures that care extends beyond the acute setting.
“Care coordination also goes beyond the hospital walls,” Hanson said. “If a patient needs services after their care, how can we ensure those connections are consistently happening?” Often a hospital discharge coordinator will help put those services in place. These and other proactive outreach efforts can help patients feel supported rather than left to figure out next steps on their own.
When care coordination fails, patients feel the impact immediately.
Coordination breakdowns can happen in electronic health record (EHR) documentation. Patients can access information in their medical chart, often almost as soon as it is created. This can cause patient frustration and confusion.
“I was looking at some notes from a recent inpatient stay. They felt so formulaic,” Knight-Rivera said. “There are also inaccuracies. What can I even do about that?” These mistakes can affect care coordination, particularly when future providers rely on the medical record. While a patient can speak to their doctor about inconsistencies or request a chart correction, both processes require more of the patient’s effort. Additionally, healthcare systems often do not advertise chart correction procedures.
At the same time, clinicians face competing demands. “There are so many things going on within their day,” Hanson said. “Time constraints are a real challenge.” These pressures influence what gets documented, how information is communicated, and what may be lost between interactions—even if it’s meaningful to the patient.
After-visit summaries (AVS) and discharge instructions are other key points of care coordination breakdown. They rely on patients reading and understanding what they say. “There’s certain information that is standard in an AVS,” Hanson said, “but information specific to the current visits needs to be easier for the patient. It needs to be right up front in a format the patient can understand.”
When those summaries are unclear, inaccurate, or buried in standardized information, they can create confusion rather than clarity. Knight-Rivera recalled a time when, after an inpatient stay, her discharge instructions included incorrect diagnoses. “It was probably just a computer error, but the information carries forward and can affect future care,” she said.
Even when communication occurs in real time, it may not result in understanding.
“Providers need to consider the state of mind of the patient when providing instruction,” Hanson said. Patients may be overwhelmed, in pain, or processing new diagnoses. Even clear explanations, devoid of medical jargon, may slip from memory in those moments.
When patients hesitate to express concerns or seek clarification, gaps in care coordination can persist, affecting adherence, outcomes, and overall experience.
The difference between effective and ineffective care coordination is often not the presence of effort, but whether that effort translates into a clear and usable experience for the patient.
Patients’ feedback is critical for enhancing care coordination since they have firsthand experience with it. A few essential strategies for doing this are:
Patients should be involved in every step of their care—including coordination. Some patients may be incapable or unwilling, but coordination should be done with them, not for them.
“We really need to engage patients in the design of our documentation and instructions,” Hanson said. Patient perspectives can highlight unseen gaps.
These are going to be different for each medical system, hospital, patient, and provider. It may be sharing more information with the patient, asking for their recommendations and preferences (when possible), or double-checking that they understand what’s happening.
“How do patients propose changes?” Hanson asked. “There’s not a drop box that says, ‘What do you think we could be doing better?’” Patient and family advisory councils are one option, and other opportunities for input may help include diverse perspectives.
Additionally, while the post-visit surveys that arrive in the mail or email may seem disconnected to the visit, they do provide valuable feedback to the system and the providers. Hanson suggests being able to fill out these surveys in real time as well as “telling patients what feedback like theirs has been able to accomplish,” she explained.
These specialists can assist patients in making sense of their medical journey while streamlining coordinating processes.
Care coordination is often most effective when it is least visible. When it works well, patients receive smooth, supportive, and responsive care. When it doesn’t, they are left to connect the dots themselves. By examining care coordination from the patient’s perspective, healthcare organizations may identify its strengths and weaknesses. Then, they can better align their systems with real-world experience.
Coordination involves more than connecting systems. It is about healthcare providers helping close the loop—ensuring that information, communication, and care come full circle in a way that makes sense to the patients at the center of it all.
*Patient’s name has been changed to protect privacy.
Jill Hanson has worked at MetaStar for almost seven years. She is most proud of having the opportunity to be part of collaborative work across the care continuum—building relationships with communities, supporting care coordination efforts, and helping share the resulting successes.
Kate Schultz is a freelance writer, standardized patient, and former high school teacher. She is proud of the blog she’s written for MetaStar and her participation in MetaStar’s goals for healthcare quality improvement.