Clinical Report: Most Decline Proactive Care Coordination

Overview

Revise to emphasize the implications of patient preferences on care coordination strategies.

Background

Proactive care coordination is intended to improve health outcomes and reduce hospital utilization, especially among older adults with cardiovascular disease. However, the effectiveness of such interventions has been inconsistent, raising questions about patient engagement and the appropriateness of care models. Understanding patient preferences and barriers to care coordination is crucial for developing effective strategies.

Data Highlights

Key Findings

• Only 27% of patients in the proactive outreach group accepted care management services.
• Among those who reported care coordination concerns, the most common reason for declining services was self-management of communication among physicians.
• The rate of ED visits or hospitalizations was similar between proactive outreach and usual care groups.
• Patients who declined care management had lower acute care event rates than those who accepted services.
• The trial's limitations included a single-site study design and a sample that was predominantly White and female.

Clinical Implications

Healthcare providers should consider patient preferences when implementing care coordination strategies, as many patients may prefer to manage their own care. Future interventions may need to focus on high-risk patients who require more intensive support to improve care coordination outcomes.

Conclusion

The study highlights the challenges of engaging patients in proactive care coordination, suggesting a need for more tailored approaches that consider individual patient circumstances and preferences.

Related Resources & Content

1. Kern LM, JAMA Network Open, 2023 -- Care Coordination and Hospitalization in Older Adults With or at Risk for Cardiovascular Disease: A Randomized Clinical Trial
2. Journal of General Internal Medicine, 2026 -- Care Transformation Organization Partnerships Are Associated with Increased Care Management Capabilities Among MDPCP Primary Care Practices
3. BMC Psychiatry, 2025 -- Feasibility of Collaborative Medication Management in Consultations at Social Psychiatric Residences: A Qualitative Interview Analysis
4. Journal of General Internal Medicine, 2026 -- Building a System-Wide Approach to Support Advance Care Planning Within an Academic Medical Center: Continuity Across Care Settings
5. The ASCO Post — COA Practice Impact Report Details Consolidation, Shift of Cancer Care System Into Hospital Setting
6. Care Coordination for High-Need, High-Cost Commercially Insured Patients: A Randomized Clinical Trial
7. Care Coordination and Hospitalization in Older Adults With or at Risk for Cardiovascular Disease: A Randomized Clinical Trial | Geriatrics | JAMA Network Open | JAMA Network
8. Calendar Year (CY) 2025 Medicare Physician Fee Schedule Final Rule | CMS