The editorial emphasis for our content in 2026 has been highlighting the elements of care delivery that impact and improve outcomes. From early intervention to managed transitions, the connective tissue holding each stage together is continuity and coordination.

Coordination is how information and care decisions flow across a team. Continuity is what happens when coordination is sustained throughout the patient’s journey.

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This article outlines the hidden costs of fragmented care and the far-reaching benefits of coordination and continuity.

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Uncovering the true scope of fragmentation in healthcare

Interoperability remains a major issue

Even hospitals that routinely exchange patient records tend to do so with other hospitals and ambulatory providers. The picture of hospital-to-SNF data sharing is considerably worse. According to an ONC report drawing on the 2023 AHA IT Supplement, fewer than one in four hospitals consistently sent electronic care summaries to most or all LTPAC partners. This included hospitals with the best track records for sharing patient records with other care partners.

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This is an infrastructure-level failure with a predictable consequence: when a patient arrives at a SNF, their clinical history often does not.

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Coordination lowers costs

A CMS-commissioned study found that patients enrolled in sustained Chronic Care Management (CCM) programs have fewer hospitalizations, use emergency services less often, and cost Medicare $95 less per patient per month in utilization.

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The research has routinely demonstrated a link between fragmentation and increased costs. An AJMC study analyzing claims from over 500,000 chronically ill, privately insured enrollees found that less care coordination was associated with $4,542 more in annual spending and higher rehospitalization rates.

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Continuity protects outcomes

The transition home presents another moment of immense risk for patients. Short-stay SNF residents have a four-times-higher risk of rehospitalization in the first two days after they return home. Residents who spent longer in a SNF, 2–4 weeks, still have a two-times-higher risk of rehospitalization in their first two days home. (Journal of American Medical Directors Association).

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Care coordination has to continue once a patient moves to a new setting. Coordination is more than a nice bonus that comes with a team that meshes well; it is a vital component of care delivery that has major impacts on outcomes.

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The numbers that reinforce the need for coordination and continuity

Coordinated care ROI: $952 net benefit per patient treated via Collaborative Care Management (CoCM) (AIMS Center)

Medication burden reduced: A 40% reduction in antipsychotic use with a coordinated team approach (Q1 Newsletter)

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In July 2025, The Lancet published one of the most compelling studies to date on the long-term impact of continuity of care: a nationwide Danish study that tracked 4.5 million patients over 16 years.

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Patients listed with the same practice for less than one year had 21% higher all-cause mortality, 25% more unplanned hospital visits, and lower cross-sectoral care continuity compared to those with 10 or more years of consistent care. Even after controlling for socioeconomic factors and comorbidities, the disparity was observed.

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Among SNFs, we see very similar patterns. Hospitals with formal SNF networks saw 4.5% lower readmission rates than hospitals without formal networks (Health Affairs). The main differentiators were effectively managed patient data and integrated physician and nurse teams continuing to visit patients during the SNF stay—more treatment in place, fewer transfers.

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Coordination and continuity are vital

While value-based care promises to improve coordination, the numbers don’t always show it as effective. Health Affairs’s study of Medicare’s Value-Based Purchasing program in SNFs found that 30-day readmissions tied to reimbursement showed no measurable improvements to readmissions, mortalities, or discharge rates.

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At Lumina Care, we’ve seen the positive impact of better coordination in care. Through our Chronic Care Management (CCM) program, our clinicians help thousands of patients and care teams manage complex care plans, coordinating with specialists and primary care on regular schedules and making proactive adjustments as needs change.

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Like CCM, Behavioral Health Integration (BHI), CoCM, and Transitional Care Management (TCM) programs are CMS-billable. This simplifies the financial picture for provider organizations, but also makes it more accessible for them to improve care coordination and continuity, and thereby improve care outcomes.

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All of these programs share a common factor: complex and chronic care is coordinated by licensed professionals, making care delivery more streamlined for patients whose needs demand coordinated, continuous care beyond the walls of a single care setting.

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At Lumina Care, we specialize in delivering these programs virtually, further eliminating the complications of physical access and geographic boundaries. Our specialists are licensed and credentialed across multiple states, enabling our clinical excellence to reach patients where it’s needed most.