coordinating care 13 mins

Coordinating Care Among Multiple Providers

Seven practical strategies for managing care across multiple doctors and specialists without dropping the ball.

Tiatun Tiatun

Written by

Tiatun Tiatun

Founder of The Care Ratings

TCR Editorial Team

Edited by

TCR Editorial Team

Editorial Review Team

Published

Fact checked

The Care Ratings Podcast

Listen instead of reading

0:00 15:38
Coordinating Care Among Multiple Providers

7 Tips for Coordinating Care Among Multiple Providers

Key Takeaways

  • Four in five Medicare beneficiaries have multiple chronic conditions requiring care from many providers—primary care doctors, specialists, hospitals, pharmacies, and home health agencies.
  • Poor care coordination leads to medication errors, redundant tests, conflicting advice, and preventable hospitalizations. Research has found that nearly all hospitalized older adults had at least one medication discrepancy in their records.
  • You don’t have to wait for providers to coordinate on their own. Designate a primary care “quarterback,” request Chronic Care Management (CCM) services, maintain a master medication list, and use patient portals.
  • Available research suggests only a minority of older adults have ever met with a formal care coordinator. Proactive steps—like bringing a caregiver to appointments—can close that gap.

Why Care Coordination Matters: The Problem Most Families Face

If your parent sees a cardiologist, an endocrinologist, a primary care doctor, and a home health nurse, you already know the problem: no single person has the full picture. Tips for coordinating care among multiple providers matter because the stakes are real and the system rarely handles this automatically.

The scale of the challenge

According to a 2021 peer-reviewed analysis published via AHRQ, four in five Medicare beneficiaries have multiple chronic conditions. Those individuals account for 64% of all clinician visits, 70% of all inpatient hospital stays, 83% of all prescriptions filled, and 93% of all Medicare spending.

That’s not a niche problem. It’s the norm for most older adults on Medicare.

CMS defines care coordination as the deliberate integration of patient care activities between two or more participants to ensure that the right care is delivered at the right time. By that standard, good coordination can eliminate redundant tests, prevent drug interactions, and save patients time and money. When it fails, the consequences are concrete.

What happens when coordination fails

Available research drawing on Health and Retirement Study data suggests that a substantial share of older adults perceive poor care coordination, including a meaningful proportion who report receiving conflicting advice from different providers.

CMS identifies the downstream effects of poor coordination: increased emergency care use, medication errors, poor transitions from hospital to home, and avoidable medical mistakes. A 2021 peer-reviewed study in the Journal of General Internal Medicine found that for 9 of 13 HEDIS clinical quality measures studied, Medicare beneficiaries who reported better care coordination also received measurably better clinical care.

The gap between what’s possible and what most families experience is wide. The seven tips below are practical ways to close it.

Tip 1: Designate a Primary Care Quarterback

When multiple providers are involved, someone needs to own the whole picture. In most cases, that’s the primary care physician (PCP)—but only if you explicitly ask them to play that role.

The numbers explain why this matters. Research published in peer-reviewed literature has historically shown that a large majority of Medicare beneficiaries see at least one specialist annually, and many see two or more—each potentially in a different practice. A 2024 peer-reviewed study found that in 2019, the average Medicare patient panel of a primary care provider saw 95 other providers annually.

Ninety-five providers. No single system connects them all automatically.

At your next PCP appointment, say this directly: “I’d like you to be the central point of contact for all my care. Can we talk about how to make sure you’re kept informed when I see other providers?” Ask the PCP’s office to request notes and discharge summaries from every specialist visit. When a new provider is added—a physical therapist, a home health aide, a new specialist—notify the PCP first.

This is also the moment to raise financial and coverage questions early. If cost or Medicaid eligibility is a concern, see Medicaid questions families should ask early.

Tip 2: Request Chronic Care Management (CCM) Services

What CCM covers

Most Medicare beneficiaries with two or more chronic conditions qualify for a program that most have never heard of. As of January 1, 2015, CMS introduced Chronic Care Management (CCM) services—billed through CPT codes 99490, 99491, and 99487—to cover non-face-to-face care coordination for qualifying beneficiaries. CCM includes coordination between a patient’s pharmacy, specialists, testing centers, and hospitals, plus a comprehensive electronic care plan and dedicated staff time of at least 20 minutes per 30-day period.

The underutilization is striking. A 2024 peer-reviewed analysis found that from 2015 to 2019, nearly 75% of Medicare fee-for-service beneficiaries were eligible for CCM services—yet the utilization rate only grew from 1.1% in 2015 to 3.4% in 2019. Three in four eligible people never used it, largely because they didn’t know to ask.

How to ask for it

At your next primary care visit, say: “I have [number] chronic conditions. Do you offer Chronic Care Management billing? I’d like to enroll.” Not every practice has the infrastructure to bill for CCM, but many do—and asking is the only way to find out. If your PCP’s office can’t support CCM, ask for a referral to a care manager or a patient navigator.

For families navigating a hospital discharge into skilled nursing or rehabilitation, see Medicare skilled nursing benefits after a hospital stay.

Tip 3: Keep a Master Medication List and Bring It Everywhere

What to include

Every prescription drug, over-the-counter medication, vitamin, and supplement your family member takes should appear on a single written or printed document. For each item, record the drug name, dose, frequency, the prescribing provider, and what condition it treats. Update the list whenever anything changes.

Bring it to every appointment—not just the PCP, but every specialist, urgent care visit, emergency room, and pharmacy.

Why it prevents harm

The risk of skipping this step is not theoretical. A 2022 peer-reviewed study found that nearly all hospitalized older adults had at least one medication discrepancy in their electronic medical record pre-hospital admission medication list. Those discrepancies are how dangerous interactions slip through.

Medication reconciliation—the process of identifying the most accurate list of all medications a patient is taking—is evidence-based and shown to reduce medication-related errors, drug therapy problems, and their associated harms.

The National Institute on Aging (NIA) warns that inappropriate polypharmacy—using excessive or unnecessary medications—increases the risk of falls, cognitive impairment, harmful drug interactions, and drug-disease interactions. Beyond safety, NIA notes it creates a significant burden for patients and families who must manage refills, timing, and side-effect recognition across many prescribing providers.

A 2025 systematic review found that long-term polypharmacy is associated with a 30% increased risk of mortality and a 61% elevated risk of hospitalization.

If you’re building a medication list for the first time before a hospital transition, the discharge planning checklist for families walks through the full process.

Tip 4: Use Patient Portals to Stay Connected Across Providers

Most major health systems now offer a patient portal—a secure online tool that lets patients view lab results, read visit notes, message providers, and review prescription histories. Peer-reviewed research published in PubMed Central has linked patient portal use to improvements in care coordination, decreased costs, and better communication between patients and providers.

The practical steps are straightforward. Set up a portal account with every provider your family member sees. If they use different systems—Epic’s MyChart at one hospital, a separate portal at a specialist’s office—maintain access to each one. Check all of them before and after appointments.

When a specialist sends a referral note or a lab result comes back, the portal is often faster than waiting for a phone call. More importantly, you can share what one provider said with another. Copy a note from the cardiologist and bring it to the PCP. Print a lab result and hand it to the specialist. The technology works best when patients use it actively rather than waiting for providers to share information with each other.

The 21st Century Cures Act and CMS Interoperability and Patient Access Rule (85 FR 25510, May 2020) established API-based data exchange standards to advance electronic health record (EHR) interoperability across systems—but implementation remains uneven. Until a fully connected system is the norm, patient portals are the most accessible tool families have.

Tip 5: Ask If Your Providers Participate in an Accountable Care Organization (ACO)

An Accountable Care Organization (ACO) is a group of doctors, hospitals, and other health care professionals that agrees to work together to provide coordinated, high-quality care. According to CMS, ACOs are designed to improve health outcomes and manage costs by sharing patient information and holding providers jointly accountable for care quality.

If your primary care doctor participates in an ACO, it means there are already built-in systems for sharing records and coordinating transitions—between your PCP and specialists, or between a hospital and a skilled nursing facility after discharge.

Ask directly: “Do you participate in an Accountable Care Organization or a Medicare Shared Savings Program?” If the answer is yes, ask what that means for your care: Who gets notified when you’re admitted to a hospital? Who follows up after discharge? Is there a care coordinator assigned to your case?

Not every practice participates in an ACO, and participation alone doesn’t guarantee good coordination. But it’s a meaningful starting question that can reveal whether structural support exists—or whether your family will need to do more of the work yourselves.

Tip 6: Bring a Family Member or Advocate to Every Appointment

Most older adults navigate their medical care alone—and most providers don’t push back on that. Available peer-reviewed research suggests that fewer than half of older adults report being accompanied to medical appointments, and only around one-third report receiving any help from family or friends in coordinating their care.

A companion serves more than an emotional function. A second person in the room catches information the patient may miss, asks follow-up questions, and remembers what was said when the patient can’t. They can take notes, request written summaries, and follow up on referrals that don’t happen automatically.

A 2018 study found that approximately 57% of older adults have involved family or friends in coordinating their healthcare at some point, but only 35% have ever spoken with a formal healthcare coordinator. Family involvement is already the most common form of coordination support—it’s just underused at the appointment level itself.

If geography makes in-person attendance difficult, most providers will permit a family member to join a telehealth visit or to be on the phone during an appointment. Ask permission in advance and confirm the provider’s preference. The goal is a second set of ears on everything that’s said, decided, and prescribed.

For families considering how to start these conversations, How families can talk about a move to care covers the communication dynamics in more depth.

Tip 7: Ask for a Shared Care Plan and Speak Up About Conflicting Advice

A care plan is a documented summary of a patient’s diagnoses, medications, goals, and the responsibilities of each provider involved in their care. Research published via AHRQ found that interoperable shared electronic care plans can allow coordination across providers and enable better communication, capturing preferences, values, goals, and progress toward attaining them.

Ask your PCP directly: “Do you have a written care plan that covers all of my conditions and all of my providers? Can I get a copy?” If CCM services are in place (see Tip 2), a comprehensive electronic care plan is a required component. If not, a written summary can still be requested and shared with every provider on the team.

When advice conflicts, say so out loud. Available Health and Retirement Study data suggests a meaningful share of older adults report receiving seemingly conflicting guidance from different providers. Providers often don’t know what another specialist has recommended unless the patient tells them. A statement as simple as “My cardiologist told me to limit fluid intake, but my nephrologist just told me to drink more—can you help me understand which takes priority?” gives your PCP the information they need to resolve the conflict.

Research on older adults with multiple chronic conditions consistently shows that patients prioritize clear communication of care plans specific to their individual circumstances and support from a coordinator who can help them sort through competing priorities. That clarity rarely happens unless the patient or a family advocate pushes for it.

For guidance on what good communication inside a care setting looks like day-to-day, see What good family communication looks like in a care setting.

What to Do Right Now: An Action Plan

The tips above are most useful when turned into concrete next steps. Here’s where to start:

  1. Book a dedicated coordination appointment with the PCP. Frame it explicitly: “I’d like to review all of my providers and medications and talk about who’s managing the big picture.” Don’t attach it to a sick visit.
  2. Ask about CCM eligibility. CMS reports that CCM is available to Medicare beneficiaries with two or more chronic conditions. If you qualify, ask the PCP’s office to enroll you and assign a care coordinator.
  3. Build the master medication list today. Include every drug, supplement, and over-the-counter product. According to CMS data, Medicare beneficiaries with six or more chronic conditions account for 62% of Medicare spending on hospitalizations—and medication errors are a leading driver of those admissions.
  4. Set up patient portal access with every provider. Log in before your next appointment. Confirm records are complete.
  5. Identify your family advocate. Decide who will attend appointments, take notes, and follow up on referrals. Set that expectation with the PCP’s office now.
  6. Ask about ACO participation. One question at your next visit can reveal whether structural coordination support already exists in your provider network.
  7. Request a written care plan. Ask for a copy after any hospitalization or major care change. Review it for gaps and conflicts before the next appointment.

According to CMS, approximately two-thirds of Medicare enrollees have multiple chronic conditions requiring coordination across primary and specialty care. The system is built around treating individual conditions, not the whole person. These steps put that responsibility back where it’s most effective: in the hands of patients and the families supporting them.

For families weighing the difference between care settings after a hospitalization, Comparing rehab options after hospital discharge breaks down the choices.

About this article: TheCareRatings.com is an independent platform that aggregates publicly available data from the Centers for Medicare & Medicaid Services (CMS), the U.S. Census Bureau, the CDC, and other federal agencies. We do not accept payment from facilities for editorial coverage or rankings. This article is for informational purposes only and does not constitute medical, legal, or financial advice. Always consult a licensed professional before making care decisions for yourself or a family member. Data referenced in this article was current as of May 14, 2026 and is subject to change.

Sources cited in this article:

Was this content helpful?