Table 1.

Adapted Framework for Care Coordination in Chronic and Complex Disease Management

	Context and Setting	Coordination Mechanisms	Emergent Integrating Conditions	Coordinating Actions	Outcomes
Within teams	• Team composition • Experience and history • Power distribution • Resources	• Plans, rules, and tools • Objects, representations, artifacts, and information systems • Roles (e.g., who contacts patients and how) • Routines • Proximity	• Accountability • Predictability • Common understanding • Trust	• Situation monitoring • Communication • Back-up behavior	• Patients (e.g., patient experience, quality of life, survival) • Health care teams (e.g., job satisfaction) • Health systems (e.g., acute care utilization, costs)
Between teams	• Multiteam system composition • Linkages between teams • Alignment of organizational cultures/ climates • Governance and payment structure			• Boundary spanning • Information exchange • Collective problem-solving and decision-making • Negotiation • Mutual adjustment

Original framework by Weaver et al. (2018)¹⁰