Workflow

Care Coordination Workflow Map & Role Matrix

A practical, end-to-end care coordination workflow with clear decision points, a role-and-responsibility matrix, ready-to-use SBAR-style handoff and referral templates, measurable KPIs, and implementation tips for technology and metrics integration—designed to reduce gaps in continuity, prevent avoidable readmissions, and make handoffs reliable and auditable.

Purpose & Reader Hunger

This workflow helps teams ensure safe, timely continuity when patients move between care settings. It focuses on clarifying ownership, standardizing handoffs, reconciling medications, surfacing social and clinical risk, and making follow-up reliable—so fewer patients fall through the cracks and care teams keep trust with patients and receiving providers.

What you get

  • A concise end-to-end workflow (admission → discharge planning → transfer → post-discharge follow-up) with key decision points and escalation triggers.
  • A role matrix that spells out who does what and when (care coordinator, attending physician, bedside nurse, pharmacist, social work, receiving-facility liaison, primary care).
  • Structured handoff templates (SBAR-style) and a sample referral form you can copy into the EHR or care platform.
  • Practical KPIs, definitions, and measurement notes so you can track performance and close loops.
  • Implementation tips for technology, dashboards, and integrating metrics with existing systems.

End-to-end Workflow (high level)

  1. Admission / Identification of coordination need

    Trigger: admission, ED visit, or referral that likely requires cross-setting support. Action: assign care coordinator and initiate care plan within 24 hours.

  2. Early discharge planning

    Decision points: expected discharge date, home vs post-acute facility, need for durable medical equipment (DME), home health, or social support. Action: complete medication reconciliation and early identification of follow-up provider and barriers (transportation, home environment, caregiver availability).

  3. Pre-discharge verification

    Checks before the patient leaves: final med reconciliation, patient/caregiver education completed, follow-up appointment scheduled, referrals sent and acknowledged, and social needs addressed or escalated.

  4. Handoff / Transfer

    Use structured SBAR and attach up-to-date problem list, medication list, advance directives, and pending results. Confirm receiving team accepts transfer and documents arrival time.

  5. Post-discharge follow-up

    Within defined window (e.g., 48–72 hours for high-risk patients): outreach by phone or in-person to confirm medication use, appointment attendance, symptom status; escalate if issues discovered.

  6. Close-the-loop verification

    Document completed referrals and results of follow-up; review readmissions and missed follow-ups as part of continuous improvement.

Key Decision Points & Escalation Triggers

  • High readmission risk score (local threshold) → automatic social work + pharmacist + primary care notification.
  • Unresolved medication discrepancies at discharge → immediate pharmacist intervention before patient leaves.
  • No confirmed receiving provider or missed appointment → escalate to unit manager/care coordination lead within 24 hours.
  • Patient reports worsening symptoms during post-discharge check → escalate to on-call clinician or arrange urgent clinic/ED evaluation.

Role Matrix (who does what)

Role Core Responsibilities Timing / Notes
Care Coordinator / Case Manager Owns discharge plan, schedules follow-ups, sends referrals, tracks completion, documents barriers Assigned within 24 hours of admission; primary contact for patient/family
Attending Physician / Hospitalist Defines clinical readiness, signs discharge orders, communicates key clinical decisions to receiving clinician Provides SBAR summary and pending items at discharge
Bedside Nurse Patient education, teach-back, final vitals, coordinate DME and home safety checks Education completed prior to discharge; documents teach-back
Pharmacist Performs medication reconciliation, reconciles home meds with inpatient meds, resolves discrepancies, provides medication counseling Medication reconciliation completed and verified before discharge
Social Worker Assesses social needs (housing, transportation, food security), initiates community referrals, arranges financial assistance as needed Engaged for high-risk patients or identified social needs
Receiving Facility / Primary Care Liaison Acknowledges referral, confirms appointment, flags constraints (capacity, admission criteria) Response required within agreed SLA (e.g., 24–48 hours)

Structured Handoff: SBAR Template (copyable)

Use this template verbatim or map fields into your EHR handoff note.

S (Situation): Patient name, MRN, current location, brief reason for transfer/discharge.
B (Background): Relevant diagnoses, recent procedures, allergy list, code status, brief hospital course.
A (Assessment): Current clinical status, outstanding issues, pending labs/images, most recent vitals.
R (Recommendation/Resources): Recommended next steps, follow-up appointments (date/time), medications to start/stop, DME requirements, home health referrals, contact for escalation.

Sample Referral / Transition Form (fields to include)

  • Patient demographics (name, DOB, MRN, preferred contact method)
  • Primary diagnosis and problem list
  • Medications at discharge (reconciled list)
  • Allergies and code status
  • Required services (e.g., SNF level of care, home health with specific tasks)
  • Follow-up appointment (date/time and contact details)
  • Pending results and responsible owner
  • Social needs / barriers and interventions planned
  • Accept/Decline field and timestamp for receiving provider

KPIs to Monitor (with definitions and suggested calculations)

  • Timely Follow-up Rate: % of discharged patients with a confirmed outpatient visit scheduled within the target window (e.g., 7 days). Numerator = patients with confirmed appointment within window. Denominator = total discharges.
  • Successful Referral Completion Rate: % of referrals acknowledged and completed by receiving provider within SLA. Numerator = referrals completed. Denominator = referrals sent.
  • Medication Reconciliation Accuracy: % of discharges with reconciled medication list validated by pharmacist or provider before departure.
  • 30-day Readmission Rate (stratified): All-cause readmissions within 30 days, reported overall and stratified by high-risk cohort.
  • Post-discharge Contact Rate: % of patients contacted within 48–72 hours post-discharge (phone or home visit).
  • Loop-closure Time: Median time from referral sent to receiving-provider acknowledgement.

Practical Implementation Tips

  • Map the workflow to your EHR capabilities—create structured discharge note templates and discrete fields for follow-up appointment, referral acceptance, and medication reconciliation status.
  • Use risk stratification to focus intensive resources on high-risk patients (e.g., prior admissions, multiple comorbidities, social vulnerability).
  • Set SLAs for receiving-provider acknowledgement and add automated escalation reminders when acknowledgements are missing.
  • Standardize communication channels: secure messaging for routine handoffs, direct phone escalation for urgent items, and a centralized referral inbox to avoid lost messages.
  • Train staff on teach-back and use checklists at discharge—embed short verification steps into the nurse workflow to reduce missed items.
  • Report KPIs on a simple dashboard (timely follow-up, referral completion, medication reconciliation completion) with weekly review by care coordination leads.

Next Steps & Adoption Checklist

  1. Map this workflow against your current discharge process and identify gaps.
  2. Customize the SBAR and referral fields to match EHR templates and local terminology.
  3. Define local SLA thresholds and high-risk criteria.
  4. Pilot the workflow on one unit or population for 4–8 weeks and collect KPI baselines.
  5. Iterate based on pilot data and scale with training, templates, and dashboard monitoring.

Governance & Continuous Improvement

Assign an owner (e.g., Director of Care Coordination) responsible for maintaining templates, reviewing KPI trends monthly, and convening rapid huddles when key metrics drift. Use root-cause reviews for missed follow-ups and readmissions to refine decision points and responsibilities.

Where interactivity helps (opportunities)

Structured forms for referrals, SBAR handoffs, and post-discharge checklists make auditing and tracking reliable. Interactive submission, saved responses, and dashboarding help close loops and provide evidence for improvement. See CapabilityEnhancementNotes for recommended platform capabilities to implement these features.

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