At Maxim Healthcare, care coordination is central to delivering seamless, safe and effective care. It helps patients navigate complex healthcare needs without gaps or confusion. When done well, it strengthens outcomes, reduces avoidable hospital visits and creates a more connected experience for patients and families. For this article, we sat down with Maxim’s Executive Director of Clinical Support Services Regina Stover to get an explanation of what care coordination is, how it works and why it’s a critical part of the care Maxim provides.
What is care coordination?
Care coordination is the intentional, organized management of a patient’s care across multiple people, settings and services. Care coordination involves deliberate communication and collaboration among everyone involved—from clinicians to caregivers to community partners—to provide the right care at the right time. Strong coordination leads to smoother transitions, fewer complications and more consistent support. Additionally, it creates a connected, informed and proactive approach to patient care. When everyone communicates effectively and works together, patients receive safer, more consistent and compassionate support throughout their healthcare journey.
Poor coordination increases the risk of medical errors, unnecessary hospitalizations and gaps in care, affecting both patient well‑being and the healthcare system. Because of this, many healthcare experts consider care coordination essential, and everyone involved in a patient’s care should participate when it’s relevant.
According to Stover, care coordination happens in real time. It may include immediate communication during a visit, follow‑up phone calls, written updates or documentation in the patient’s record. It becomes especially important during transitions of care, such as hospital discharges, changes in services or shifts in a patient’s health status. These moments carry a higher risk for confusion or missed information, making timely communication critical.
How does Maxim use care coordination?
The purpose of care coordination is to achieve safe, appropriate and effective health outcomes. It helps bridge gaps between providers, reduces duplication of services and lowers the risk of hospitalization or rehospitalization. When done well, it promotes a more unified experience and improved outcomes for patients, and a more efficient process for the healthcare team.
“In a hospital setting, care is more centralized; all resources and specialists are typically available under one roof,” says Stover. “In homecare, while the patient benefits from a higher level of comfort and autonomy, not all care team members are physically present in the home at once. This reality requires a much more deliberate approach to communication. At Maxim, we focus on aligning every clinician, family member and specialist to prioritize patient safety and prevent gaps in care.”
Who participates in care coordination?
Stover states that care coordination involves a wide range of people. Aides, therapists, nurses, social workers and supervisors support the patient’s daily needs. Physicians, payer case managers, durable medical equipment companies and pharmacies contribute to the effective clinical management and resources required to keep each patient safe. Patients, families, authorized representatives, recruiters, business development teams, discharge planners and transitional care coordinators also play a role, each bringing a different perspective and responsibility. Together, they form a network working toward a shared goal: safe, effective and seamless care.
Coordinating care wherever patients are located
Care coordination includes organizing care activities, exchanging information, collaborating on goals, arranging services, connecting patients with community support and responding to changes in condition. These activities can occur anywhere that the patient receives care—inpatient or outpatient facilities, clinics, pharmacies, physician offices or the patient’s home.
Recognizing and reporting changes in condition
According to Stover, one of the most important responsibilities in care coordination is promptly recognizing and reporting changes in a patient’s condition. This includes, but is not limited to, shifts in vital signs, pain, skin integrity, injuries, respiratory events, medication issues or the use of backup medical equipment. It also includes reporting treatment refusals, any medication concerns, emergency activations, suspected abuse or neglect, falls, complaints, new orders, upcoming procedures, safety concerns in the home, physician visit updates and supply shortages. Significant changes involving the patient’s family or support system should also be considered. Timely reporting allows the care team to respond quickly, adjust the plan of care and prevent complications.
Maxim Healthcare provides a range of home health and personal care services. To inquire about the care and services provided, visit our locations page.
