Stage 11: Continuity & Care Coordination
Concept 4 of 8
E11.4

Care Coordination

Most psychiatric patients have multiple providers — PCP, therapist, specialist, case manager. Coordinate or care fragments.

Encounter card
Setting
Any patient with multiple providers or specialty involvement.
Opening move
Identify the team. Communicate with relevant team members — letter, phone, secure messaging. Know who's doing what. Avoid duplication or gaps.
Sample language
  • "(to patient) Can I send a note to your PCP about your medication changes?"
  • "(to therapist by message) Wanted to update you on med changes — here's what I changed and why."
  • "(to social worker) Can we coordinate on housing — that's affecting medication response."
Listen for
Whether other providers know what you're doing. Whether the patient knows what each is doing. Gaps in coordination.
Common pitfalls
Operating in isolation. Failing to update PCP on psychiatric medications. Therapist and psychiatrist not aligned. Case manager unaware of clinical changes.

Red flags / escalate: Conflicting recommendations from different providers confusing the patient. Important clinical information not communicated between team members.

Documentation
Communications with other providers documented. Updates sent.

Psychiatric care almost always involves multiple providers. The coordination is part of the work, not optional.

Warm grey-tinted clinical notebook page, soft mauve accent. The team around a patient — PCP, therapist, psychiatrist, case manager, specialist. Margin clusters on each role.

Psychiatric care is almost always team care, whether or not the team operates formally. The patient typically has a primary care physician, often a therapist, sometimes a specialist for medical comorbidity, sometimes a case manager, sometimes school or workplace personnel involved. Coordinating across the team is part of the work; failure to coordinate produces fragmented care and missed opportunities.

Map the team. Identify who's involved in the patient's care. Get releases as appropriate. Know the names, contacts, and roles. The patient who has a PCP, a therapist, a cardiologist, and a case manager has four other people contributing to their care; your work intersects with each of theirs.

Active communication, not waiting to be asked. After medication changes, a brief message to the PCP — what changed, why, what to monitor. After psychiatric hospitalization, an update to the outpatient team. After meaningful changes in clinical status, alert relevant team members. The clinician who initiates communication produces better team coordination than the one who waits for requests.

Format for the receiver. Letters to PCPs in clinically appropriate language. Brief messages through electronic systems when available. Phone calls for time-sensitive or nuanced issues. Adapt the communication to the audience and the channel.

Clarify roles when needed. Sometimes overlapping providers create confusion — who manages the medication for ADHD when the primary care doctor started it and the patient now sees you? Who handles refills when therapy is with one clinician and prescribing with another? Make role boundaries explicit when ambiguity emerges.

Avoid duplication and gaps. Two prescribers prescribing similar medications. Two therapists providing different therapy modalities without coordination. No one managing a specific symptom that fell between providers. Periodic team coordination prevents these.

Family as part of the team when patient consents. Spouse, parent, adult child often have important roles in the patient's care and benefit from being informed and aligned.

Document the communications you make. Letters, phone calls, messages — note that they occurred. The chart shows the coordination work that supports the patient's care.

Active communication between providers — letters, phone, secure message. Margin notes on the practice.
The anchor

Psychiatric care is almost always team care. Coordinate actively — communicate, clarify roles, share plans, prevent gaps and duplication.

Avoiding duplication or gaps — clear roles, shared plan. Margin clusters on coordination moves.
Prove it

You're seeing a patient with depression who also sees a therapist for CBT, has a PCP, and a case manager for housing. How do you coordinate?

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