Care Coordination

A patient needs a follow-up visit. Someone has to review the assessment, contact the patient, arrange the visit, and make sure the result gets back to the care team. Each step is straightforward on its own. Keeping track of who owns the next step is where care coordination becomes useful.

This section covers operational workflows across the practice, from a shared task queue to ongoing patient case management. Medplum provides the FHIR resources, search, access policies, and automation tools you can combine to build these workflows.

Start with the workflow

Use the Care Coordination Decision Guide to work through ownership, handoffs, and follow-up with your team. You can start with Tasks and add a case or clinical plan as your care model needs it.

Start with the Work Your Team Needs to Do

Need	Model	What it represents
Assign and track an action	Task	A unit of work with its own owner, lifecycle, inputs, and outputs
Request a clinical service	ServiceRequest or another specific request resource	The clinical request or authorization that work fulfills
Coordinate ongoing participants	CareTeam	People and organizations involved in care, with roles and participation periods
Track responsibility across visits	EpisodeOfCare	A period of responsibility for a patient, including organization, coordinator, and team
Agree on a patient's care	CarePlan and Goal	Intended activities and objectives, with evidence of progress
Reuse a clinical protocol	PlanDefinition and ActivityDefinition	Definitions that can be applied to patient-specific work

This diagram shows one directly authored plan. Resources also carry their own patient references. The supportingInfo association is an application convention; a shared Condition alone does not establish case membership. Protocol-generated plans can have an intermediate RequestGroup.

Build Your Care Coordination Workflow

1. Tasks and Work Queues: identify work, expose queues, and claim items safely.
2. Teams, Assignment, and Top-of-License Care: assign eligible roles and preserve required review.
3. Handoffs, Deadlines, and Escalation: define completion evidence, dependencies, and exceptions.
4. Longitudinal Patient Case Tracking: maintain continuity and responsibility across visits.
5. Care Plans, Goals, and Progress: connect planned work to clinical objectives.
6. Automating Care Workflows: create and advance work reliably.
7. Clinical Decision Support and Follow-Through: connect guidance to review and action.
8. Operational Reporting: measure workload, delays, and outcomes.

Connect the Rest of the Practice

Referrals, messaging, and scheduling use these coordination patterns. Keep domain-specific clinical records in those models and use Tasks for the work around them. Clinical Protocols covers reusable definition authoring.

Enforce visibility through AccessPolicy and ProjectMembership. Assignment and CareTeam membership do not automatically grant access. Populate each resource's own patient references, including work created by Bots.

For the operational motivation, see Digital Health is an Operations Game, particularly its discussion of task classification, delegation, and asynchronous care.