Coordinated and Integrated Care Models

Coordinated and integrated care models describe formal organizational and clinical arrangements in which providers, facilities, and support services share information and responsibility to deliver patient care across multiple settings. These models address fragmentation — a structural failure in which patients receiving care from disconnected providers experience gaps, duplications, and adverse outcomes. The scope covered here includes the defining frameworks, regulatory context, operational mechanisms, primary model types, and the classification boundaries that distinguish coordination from integration in the United States health system.

Definition and scope

Care coordination and care integration are related but distinct concepts. The Agency for Healthcare Research and Quality (AHRQ) defines care coordination as "deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care." Integration goes further — it describes the structural or organizational unification of previously separate services, financing streams, or provider entities.

The Centers for Medicare & Medicaid Services (CMS) operationalizes these concepts through payment and delivery reform programs, including the Medicare Shared Savings Program (MSSP) and the Comprehensive Primary Care Plus (CPC+) model. At the statutory level, the Affordable Care Act (ACA, Public Law 111-148) established the Center for Medicare and Medicaid Innovation (CMMI) specifically to test and scale integrated delivery arrangements.

The scope of coordinated and integrated care spans three service-level categories:

1. Clinical coordination — aligning treatment plans, medication management, and follow-up across providers
2. Behavioral and physical health integration — co-locating or formally linking mental health services and primary care services under shared protocols
3. Social and community service linkage — connecting clinical care to housing, nutrition, and transportation supports through documented referral pathways

How it works

Operational integration typically follows a staged framework recognized by the SAMHSA-HRSA Center for Integrated Health Solutions (CIHS), which classifies arrangements across a six-level continuum from minimal collaboration to full integration. The six levels progress as follows:

1. Level 1 — Minimal collaboration: Providers operate at separate facilities with no systematic communication.
2. Level 2 — Basic collaboration at a distance: Providers share occasional consultation but maintain independent systems.
3. Level 3 — Basic collaboration on-site: Different providers share a physical location but use separate records and workflows.
4. Level 4 — Close collaboration with some system integration: Shared screening tools and periodic case conferences; partially unified records.
5. Level 5 — Close collaboration approaching an integrated practice: Regular team meetings, unified treatment plans, and shared electronic health records (EHRs).
6. Level 6 — Full collaboration in a transformed/merged practice: A single, merged practice culture with fully integrated records, financing, and clinical workflows.

Health information exchange (HIE) functions as a technical substrate for Levels 4 through 6. The Office of the National Coordinator for Health Information Technology (ONC) governs interoperability standards under the 21st Century Cures Act (Public Law 114-255), which prohibits information blocking and mandates FHIR-based data exchange. Without HIE infrastructure, coordination degrades into manual telephonic handoffs, which research published through AHRQ identifies as a primary vector for medication reconciliation failures.

The medical referral process intersects with integration at transition points — specifically at hospital discharge, specialist referral, and post-acute care handoffs. Accountable care organizations and value-based care arrangements formalize financial accountability for these transitions by attributing total cost of care to a defined provider network.

Common scenarios

Integrated care models appear across a range of delivery contexts. Four distinct scenarios account for the majority of structured implementations documented by CMS and AHRQ:

Federally Qualified Health Centers (FQHCs): Under Section 330 of the Public Health Service Act (42 U.S.C. § 254b), FQHCs are required to provide comprehensive primary and preventive services regardless of ability to pay. Many FQHCs operate integrated behavioral health programs under the HRSA Health Center Program guidelines. The community health centers and federally qualified health centers model exemplifies Level 5–6 integration in publicly funded settings.

Patient-Centered Medical Homes (PCMH): The National Committee for Quality Assurance (NCQA) administers the PCMH recognition program, which requires documented care coordination processes, population health management, and 24/7 access standards. As of the NCQA 2023 program standards, PCMH recognition requires evidence of active care team roles, including dedicated care managers for high-risk patients.

Inpatient-to-Post-Acute Transitions: Hospital systems and inpatient services that participate in CMS bundled payment programs under the Bundled Payments for Care Improvement Advanced (BPCI-A) model are contractually required to coordinate discharge planning with home health care services and rehabilitation and physical therapy services. The Medicare Conditions of Participation (42 CFR § 482.43) set minimum discharge planning standards for all Medicare-participating hospitals.

Chronic Disease Management Programs: Patients managing conditions such as diabetes, heart failure, or COPD are addressed through chronic disease management services that depend on structured care coordination protocols aligned with clinical guidelines from bodies such as the American Diabetes Association and the Agency for Healthcare Research and Quality.

Decision boundaries

The distinction between coordination and integration carries regulatory and operational weight. Coordination can exist without organizational merger — a primary care physician coordinating with a cardiologist via a shared EHR constitutes coordination, not integration. Integration implies shared governance, shared financial risk, or merged organizational identity.

Three classification boundaries define where a model falls on the spectrum:

• Structural integration exists when two or more provider entities operate under a single tax identification number or a shared governing body, as recognized by IRS and CMS enrollment rules.
• Clinical integration exists when independent providers share protocols, performance metrics, and patient data through a formal clinical integration program — a standard the Federal Trade Commission (FTC) has defined in advisory opinions as requiring active and ongoing collaboration to improve quality and efficiency.
• Financial integration exists when providers share capitation, global budgets, or downside financial risk through a vehicle such as an Accountable Care Organization or a managed care contract.

Behavioral health integration in medical settings presents a specific classification challenge: co-location alone does not constitute clinical integration under NCQA or SAMHSA standards unless shared treatment planning and unified records are documented. The medical service accreditation and quality standards frameworks administered by The Joint Commission and URAC include integration-specific standards that surveyors use to distinguish structural co-location from functional integration.

Regulatory enforcement boundaries also apply. HIPAA's Privacy Rule (45 CFR Parts 160 and 164), administered by the HHS Office for Civil Rights (OCR), governs what patient information can be shared across integrated care teams. An Organized Health Care Arrangement (OHCA) designation under HIPAA permits participating providers to share a joint Notice of Privacy Practices, a status that reflects — but does not create — integration.

References

• Agency for Healthcare Research and Quality (AHRQ) — Care Coordination
• Centers for Medicare & Medicaid Services (CMS) — Accountable Care Organizations
• SAMHSA-HRSA Center for Integrated Health Solutions (CIHS)
• Office of the National Coordinator for Health Information Technology (ONC) — Health Information Exchange
• National Committee for Quality Assurance (NCQA) — Patient-Centered Medical Home
• Federal Trade Commission (FTC) — Clinical Integration
• HHS Office for Civil Rights — HIPAA Privacy Rule
• U.S. Code 42 U.S.C. § 254b — Federally Qualified Health Centers
• Electronic Code of Federal Regulations — 42 CFR § 482.43 (Discharge Planning)