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Care Coordination

Definition

Care Coordination (CC) [Canada – Insurance Context]: An organized, insurer-supported process whereby an individual’s health, disability, and wellness care are actively managed across multiple providers, payers (public or private), and community resources to prevent service gaps, reduce duplication, control costs, and achieve the outcomes most valued by the patient and covered under their provincial health plan and/or supplemental insurance policy. In Canada this typically includes: (1) assigning one care coordinator (often a nurse case-manager or rehabilitation consultant) paid or recognized by the insurer; (2) sharing relevant clinical and insurance authorization data among the patient’s physicians, allied-health professionals, home-care programs, and the insurer while respecting federal PIPEDA and provincial privacy statutes; (3) scheduling and sequencing insured benefits (e.g., medically necessary surgery, physiotherapy, drug coverage, income-replacement disability benefits) in line with provincial coverage rules and/or the terms of supplementary extended-health or recommended external resources; and (4) reporting back to the insurer on functional goals and return-to-work status. The overarching aim is to align insured entitlements with evidence-based care pathways so the right service is delivered to the right patient by the right provider at the right time—without exceeding allowable plan limits or causing unnecessary out-of-pocket expenses.

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