Table 1 Weaver et al. framework for care coordination in chronic and complex disease management
Context and Setting (moderators or inputs) | Coordination mechanisms (Inputs) | Emergent integrating conditions (mediators) | Coordinating actions (proximal, behavioral processes) | Outcomes (proximal and distal outcomes) | |
|---|---|---|---|---|---|
Within teams | • Team composition • Experience and history • Power distribution • Resources | • Plans, rules, tools (e.g., standardized care protocols) • Objects, artifacts, information systems, representations | • Accountability • Predictability • Common understanding • Trust | • Situation monitoring • Communication (information sharing and collective sensemaking) • Back-up behavior | • Proximal health outcomes • Proximal care costs • Satisfaction |
Between teams | • Multiteam system composition • Linkages between teams • Alignment of organizational cultures/climates • Governance and payment structure | • Boundary spanning • Collaborative sensemaking: ◦ Information exchange ◦ Collective problem solving and decision-making • Entrainment: ◦ Negotiation ◦ Mutual adjustment | • Distal health outcomes for individual patients (e.g., mortality) • Public health outcomes • Lifetime care costs and value • Satisfaction • Timeliness of care |