Care Coordination
Creating Connection Across the Care Journey
When Care Is Not Coordinated, People Carry the Burden
Fragmented care is often described as a technology problem. One system does not connect to another. A record is unavailable. A test result does not follow the patient. A provider cannot see information that exists somewhere else. But fragmentation is not experienced as a technology problem by the people caught inside it. It is experienced as work.
A patient has to remember which medication changed. A caregiver calls another physician’s office to find a missing result. A primary care provider searches for records from a specialist. A care manager tries to determine whether follow-up ever happened. Each individual action may seem small, but together they reveal something much larger: when healthcare does not coordinate effectively, the work of creating that coordination does not disappear. Someone has to absorb it.
CMS defines fragmented care as care in which healthcare providers do not communicate effectively with one another. The consequences can include repeated testing, conflicting medications, unnecessary appointments, poor transitions, medical errors, emergency care, and higher costs for patients. The more complex the patient’s healthcare journey becomes, the more consequential those communication gaps can be.
More Providers Can Mean More Opportunities for Information to Break Down
Receiving care from multiple providers is not inherently a problem. For people managing chronic or complex conditions, seeing a primary care physician and several specialists may be exactly what appropriate care requires. The challenge is whether those providers can see enough of the same patient story to make coordinated decisions.
A 2026 randomized clinical trial published in JAMA Network Open examined 400 Medicare beneficiaries age 65 or older who had cardiovascular disease or related risk factors and had experienced highly fragmented ambulatory care. These individuals had a median of 14 ambulatory visits with eight different physicians during the previous year. The researchers noted that seeing multiple physicians can increase the risk of communication gaps even in an era of electronic health records, and previous research has associated fragmented care with greater use of emergency departments and hospitals.
Fourteen visits and eight physicians represent a significant amount of information to keep aligned. The presence of an electronic health record does not automatically mean that every member of the care team has the information they need, when they need it, in a form they can readily use.
When the System Does Not Carry the Information, the Patient Often Does
Patients should be active participants in their healthcare. They should understand their diagnoses, medications, treatment options, and next steps, and they should have meaningful access to their own information. But participation is different from being responsible for connecting the healthcare system.
When records, medication lists, test results, discharge information, and care plans do not move consistently across settings, patients and caregivers often become the communication channel between organizations. They request records, explain previous diagnoses, try to remember medication changes, confirm whether a specialist received a test result, and ask one physician whether another physician has called.
For someone managing multiple conditions, those responsibilities can become substantial. CMS emphasizes care coordination because people with complex health needs may receive care across multiple providers and settings, and ineffective communication can contribute to medication conflicts, repeat testing, poor transitions, and other adverse outcomes. Patients should help make decisions about their care. They should not have to reconstruct their care every time they enter a different part of the healthcare system.
A coordinated experience should give patients visibility and control while reducing the number of administrative and informational tasks they must complete simply to keep everyone else informed.
Providers Carry the Burden Too
Fragmentation also changes the work of the provider. A physician may begin an appointment without recent laboratory results, an updated medication list, hospital discharge information, or notes from another specialist. The information may exist, but if it is not available within the workflow where a decision is being made, its existence provides limited value.
That can leave providers spending valuable time searching for records, asking patients to reconstruct their history, contacting other offices, or repeating services because they cannot verify what has already been completed. In some situations, clinicians may have to make decisions without a complete picture of the patient’s recent care.
This is why data access alone does not create coordinated care. Information needs to be current, understandable, relevant, and available where clinical and operational decisions actually occur. Healthcare has made enormous progress in digitizing information and expanding data exchange, but connected systems are only useful when they support connected workflows.
Care Coordination Is Not Simply a Program You Add
The 2026 JAMA Network Open trial offers another important lesson: identifying fragmentation and adding a care coordination intervention does not automatically solve the problem.
Researchers compared the usual approach of offering care coordination after hospitalization with proactive outreach to patients who reported coordination problems before a hospitalization occurred. Proactive outreach did not reduce emergency department visits or hospitalizations compared with usual care. Among intervention participants who were eligible for coordination, only 26.5% accepted the service. The most common reason for declining was that participants said they were coordinating their own care.
That finding does not mean care coordination lacks value. It raises a more useful question: what kind of coordination do patients actually need, when do they need it, and how should it fit into the care they are already receiving?
A coordination program cannot succeed simply because it exists. Organizations have to consider how patients are identified, when support is offered, whether patients understand the value of that support, what information care managers can access, and whether coordination is connected to the providers and workflows already involved in the patient’s care.
A 2024 JAMA Network Open study examining person-centered care planning for people living with multiple chronic conditions reached a similar conclusion from a broader implementation perspective. Researchers identified multidisciplinary teams, care coordination, digital health technology, workflow design, education, payment models, goal alignment, and meaningful measurement as interconnected components of effective person-centered care. Coordination is not one intervention. It is an operating model.
What Coordinated Care Should Actually Accomplish
CMS describes care coordination as organizing an individual’s care across multiple healthcare providers. The purpose is not simply to make systems technically connected. It is to help ensure that a patient’s needs and preferences are known, communicated to the right people at the right time, and used to support safe, appropriate, and effective care.
For healthcare organizations, that definition needs to become operational. Effective coordination should mean that providers can access relevant clinical information when making decisions, medication lists and care plans remain current across settings, and test results and specialist recommendations reach the people responsible for acting on them. It should mean that transitions between hospitals, specialists, primary care providers, and post-acute settings have clear ownership rather than assumptions about who will follow up.
Most importantly, patients should understand what happens next without becoming the primary communication channel between everyone involved. CMS’s current Optimizing Care Delivery Framework reinforces many of these same priorities, including safer and more coordinated care transitions, reducing unnecessary administrative burden, improving care approval processes, reducing redundant documentation, and using technology to improve the care experience.
Technology can support every one of those objectives, but technology alone cannot create them. The information still has to reach the right person, fit the workflow, clarify responsibility, and lead to action.
Where the Health Access Card® Fits
The Health Access Card® is designed to address one important part of that coordination challenge: helping make patient-authorized health information available when and where care is being delivered.
Instead of relying entirely on a patient’s memory, paper records, or separate requests between offices, the Health Access Card® provides a secure, permission-based way for individuals to authorize access to available health information. Built using FHIR® standards, it can help providers gain additional context about the person in front of them while keeping the individual in control of how their information is shared.
The Health Access Card® is not intended to replace electronic health records, care managers, clinical judgment, or the operational work required to coordinate healthcare across organizations. Its value is much more practical: helping reduce one of the places where fragmentation places unnecessary responsibility back on the patient.
If a patient arrives somewhere new, they should not have to rely solely on memory to explain every part of their healthcare history. If relevant information is available and the patient chooses to share it, that information should be easier for the provider to access and use. That can give the provider more context, give the patient greater control, and reduce some of the friction created when care moves from one setting to another.
The Real Measure of Coordination
Healthcare will always involve multiple people, organizations, systems, and settings. The solution to fragmentation is not to eliminate that complexity. It is to make sure the patient does not have to personally hold all of those pieces together.
Healthcare organizations need to look closely at where communication breaks down, which information fails to follow the patient, where responsibilities become unclear, and which coordination tasks are quietly being transferred to patients, caregivers, physicians, nurses, and care managers. Some gaps can be addressed through technology. Others require clearer workflows, better accountability, stronger communication, or different approaches to care management. Most will require a combination of all of them.
The important question is not simply whether healthcare organizations have connected systems or launched a care coordination program. It is whether the people delivering and receiving care experience that coordination when it matters. When information follows the patient, providers can make decisions with greater context. When responsibilities are clear, care teams spend less time determining who should act next. When patients have access and visibility without being asked to manage the process themselves, participation becomes empowering instead of burdensome.
The question is no longer whether fragmented care exists. It is how much of the burden of fixing it we are still willing to place on the people healthcare is supposed to serve.
Sources
CMS Care Coordination
JAMA Network Open: 2026 randomized clinical trial on highly fragmented ambulatory care
JAMA Network Open: 2024 study on person-centered care planning
CMS Optimizing Care Delivery Framework
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