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