Care Coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care. This means that the patient's needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient.

Care Coordination services include:

• Establishing accountability and agreeing on responsibility.
• Communicating/sharing knowledge.
• Helping with transitions of care.
• Assessing client needs and goals.
• Creating a proactive care plan.
• Monitoring and follow up, including responding to changes in client needs.
• Supporting clients self-management goals.
• Linking to community resources