Fragmented care — where a patient's specialists, primary care provider, and care settings don't communicate — is a well-documented driver of poor outcomes and wasted cost. NURS6620 surveys the care delivery models designed specifically to solve that fragmentation.
Major care coordination models
NURS6620 covers the patient-centered medical home (PCMH) model, accountable care organizations (ACOs), and health homes for populations with chronic or behavioral health needs — examining how each model structures accountability, financial incentives, and care team roles differently to achieve better-coordinated care. Students compare how these models each attempt to solve the fragmentation problem through different structural and financial mechanisms.
Population health management within care coordination
The course connects care coordination to population health management — risk-stratifying a patient population to identify who needs intensive care coordination versus routine care, and using registries and predictive analytics to proactively identify patients likely to benefit from coordinated intervention before a crisis (like an ED visit or hospitalization) occurs.
Key topics in NURS6620
- The patient-centered medical home (PCMH) model and its core attributes
- Accountable care organizations (ACOs) and shared-savings financial models
- Health homes for chronic disease and behavioral health populations
- Population health risk stratification for targeting care coordination resources
- Using registries and predictive analytics for proactive care coordination
- Comparing how different care coordination models structure accountability and incentives
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Worked example: risk-stratifying a population for care coordination
- Population: A primary care panel of 2,000 patients
- Risk stratification: Predictive model scores each patient based on chronic conditions, prior utilization, and social risk factors
- High-risk tier (top 5%): Assigned an intensive care coordinator with frequent proactive outreach
- Rising-risk tier (next 15%): Receives periodic care management check-ins and care gap outreach
- Low-risk tier (remaining 80%): Managed through standard primary care without dedicated coordination resources
- Lesson: Care coordination resources are finite and should be targeted using data, not applied uniformly across an entire population
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Frequently asked questions
The patient-centered medical home is a primary-care-based model built around a small set of core attributes: comprehensive care (addressing the majority of a patient's physical and behavioral health needs), patient-centered care (built around the whole person, not just isolated conditions), coordinated care across specialists, hospitals, and community services, enhanced access (extended hours, same-day appointments, various communication channels), and a systematic approach to quality and safety. It's designed specifically to counteract the fragmentation problem common in traditional fee-for-service primary care, where a patient's specialists, primary care provider, and various care settings often operate in silos with poor communication, leading to duplicated tests, conflicting treatment plans, and missed opportunities to catch problems early. NURS6620 teaches PCMH as one of several structural responses to this fragmentation problem, distinguished from ACOs by its focus specifically on the primary care practice as the coordinating hub, rather than a broader network-level accountability structure.
Intensive care coordination — dedicated care coordinators, frequent proactive outreach, detailed care planning — is resource-intensive and expensive to provide, and most patients in a given population don't need that level of intervention to achieve good outcomes; applying it uniformly across an entire patient population would be both financially unsustainable and an inefficient use of limited care coordination staff. NURS6620 teaches risk stratification specifically because it allows organizations to concentrate their most intensive, expensive care coordination resources on the smaller subset of patients — often those with multiple chronic conditions, high prior healthcare utilization, or significant social risk factors — who are both at genuine risk of poor outcomes and most likely to benefit from coordinated intervention, while managing the larger, lower-risk portion of the population through standard, less resource-intensive primary care. This targeted approach produces better population-level outcomes per dollar spent than either uniform intensive coordination (unaffordable at scale) or no coordination at all (leaving genuinely high-risk patients without needed support).