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Healthcare has been steadily expanding beyond the confines of traditional medical settings as the industry shifts toward person-centered care to help address social determinants of health among at-risk individuals. As such, care for one individual may include multiple providers across a variety of settings, creating the need for tighter coordination between providers to ensure no one slips through the cracks. In partnership with Aetna, Meals on Wheels America seeks to develop a comprehensive understanding of the current state of care coordination across all levels of healthcare and community support so as to learn more about the approaches to care coordination that hold the greatest promise for improving health outcomes, reducing healthcare costs, and being scaled through existing networks.






Designing and implementing a care coordination strategy that facilitates and ensures stability outside of traditional medical settings has the potential to increase patient satisfaction and improve health outcomes while decreasing the number of costly and unnecessary emergency room visits and hospitalizations. To better understand the current care coordination environment, Meals on Wheels America and Aetna set out to examine numerous care coordination strategies currently in use across the country. Demystifying Care Coordination explores promising practices and approaches to care coordination, as well as challenges that need to be addressed to facilitate successful scaling and wider adoption. This report:

  • Examines the varied definitions of care coordination used among those serving high-risk populations;
  • Highlights different care coordination models currently in use among transition care and community-based care providers;
  • Describes key goals, principles and elements present in each care coordination model; and
  • Identifies promising practices and challenges from each model that may be used to further develop and scale a widespread approach to care coordination.

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You can view a short on-demand webinar to explore issues with fragmented care, gain a closer look into this white paper and learn how you can apply its findings. Access this webinar here.

This report is intended to be disseminated freely. In reproducing any excerpts of this report, please provide a credit, such as: “Demystifying Care Coordination was prepared by Meals on Wheels America and Aetna, a CVS Health business. The views expressed are those of the authors and do not necessarily reflect the position or policy of Meals on Wheels America.”