Care Coordination

Coordinated care is foundational to achieving optimal health outcomes, especially for patients managing co-occurring physical and mental health conditions. Behavioral health and primary care providers often care for overlapping patient populations, many of whom are at heightened risk for fragmented care, medication mismanagement, and poor outcomes due to systemic barriers. The World Health Organization emphasizes that integrated, person-centered care leads to better management of chronic illnesses, improves patient satisfaction, and reduces health disparities6. Additionally, the National Institute of Mental Health reports that individuals with mental health disorders are more likely to develop chronic physical illnesses such as diabetes, cardiovascular disease, or respiratory conditions3. These individuals are also more likely to experience social determinants of health that can interfere with treatment adherence, including housing instability, food insecurity, and lack of transportation.

For historically marginalized communities, including racial and ethnic minorities, LGBTQ+ individuals, and people living in poverty, coordinated care becomes even more critical. These populations experience disproportionately higher rates of behavioral health disorders, yet often face limited access to culturally competent care and continuity of services. Ensuring seamless collaboration between medical, behavioral health, and community-based providers not only improves clinical outcomes but also helps address social needs that heavily influence health status and recovery. Effective care coordination empowers providers to take a team-based approach and create integrated care plans that consider the whole person.

Best practices in Coordinated Care:

  1. Multidisciplinary team-based care: Involve PCPs, BH providers, social workers, care coordinators, and community health partners.
  2. Culturally responsive communication: Use interpreters and culturally appropriate materials; train staff in trauma-informed and equity-based approaches1.
  3. Shared care plans: Engage patients and families in creating integrated care goals across disciplines.
  4. Health IT integration: Enable real-time EHR sharing to reduce duplication and enhance follow-up.
  5. Address Social Determinants of Health (SDoH): Screen for and respond to needs such as food insecurity, transportation, and housing.
  6. Continuous monitoring and follow-up: Track engagement, outcomes, and adjust care based on real-time needs.
  7. Evaluate and improve: Use data on health equity, patient experience, and access to guide ongoing quality improvement efforts4.