About This Series: This case study is part of a GLC4HSR and ACCESS Health International series, 'Resilience in Action', unpacking presentations from the GLC4HSR Annual Conclave 2026 for a wider audience. It is designed to bridge the gap between technical policy discussions and actionable health systems insights. 

About the Presenter: This document is based on a presentation delivered by Ms. Shalini Singh on behalf of Arohan, in the Care Coordination session of the GLC4HSR Annual Conclave 2026.

Introduction

A patient discharged after a cardiac event, a mother navigating a high-risk pregnancy, a person newly diagnosed with diabetes; each depends on a chain of providers, facilities, and handoffs that, more often than not, was never designed to function as a chain at all. Ms. Shalini Singh's presentation at the GLC4HSR Annual Conclave 2026 made the case that this missing connective tissue, care coordination, is its core, even though it is rarely treated as one.

Care coordination can be understood through the image of a helix: two intertwined strands, the patient's complex care journey on one side and the continuum of care on the other, held together by the interconnections between them. Those interconnections are the bonds that make care linkages possible. When they hold, they form the code for a well-functioning primary health system. When they don't, the system fragments in ways patients feel long before policymakers measure them. 

Why a care coordination model, now

The presentation identifies four clusters of coordination failure already plaguing the health system.

• The first is outright fragmentation: health facilities, diagnostics, laboratories, and private providers largely operate in isolation from one another, and multiple public health programmes run in parallel with minimal integration between them. 
• The second is weak continuity and referral infrastructure: poor linkages between levels of care, weak gatekeeping at the primary level that burdens tertiary facilities, inadequate tracking that leads to patients being lost to follow-up, and poor handoffs when patients transition from hospital back to home. 
• The third is a persistent information and communication gap, both between providers at different levels of care and between providers and the patients they treat. 
• The fourth is uneven quality and a limited orientation toward prevention: treatment guidelines vary widely across providers, and health promotion and preventive education remain underinvested.

The human cost of poor coordination

Ms. Singh’s presentation translates these systemic gaps into patient-level consequences, and the numbers are stark. 

Coordination failure is not only a patient-facing problem; it is also a provider-facing one. Provider delays in referral and poor case management are implicated in 92% of maternal deaths, underscoring how much rests on timely clinical decision-making and escalation. Digital infrastructure to support this decision-making is thin: in one South Indian study, only six of fifteen facilities had an electronic health record system capable of tracking diabetes. Where care requires multiple health teams, as in palliative or cancer care, unclear role definitions create confusion and can fracture partnerships between providers altogether. Referral communication is often minimal, inconsistent, and handwritten, and providers report a lack of structured mechanisms for referring patients to the right facility in the first place. 

Layered on top of this is provider burnout, with nearly a quarter of the workforce reporting emotional exhaustion, and a persistent lack of integrated protocols for managing multiple long-term conditions, even where single-disease protocols exist.

Beyond individual facilities and providers, the note points to structural gaps that keep the system fragmented. Patients themselves tend to bypass the primary level: one study found 40 percent of urban residents go directly to specialized clinics or hospitals regardless of the severity of their condition, overcrowding tertiary facilities in the process. Programme management and monitoring systems, meanwhile, are not built for the kind of long-term, lifestyle-oriented care that NCDs demand. And India's flagship insurance scheme, the Pradhan Mantri Jan Arogya Yojana (PM-JAY), covers inpatient care at secondary and tertiary facilities; it does not integrate with primary care, offers limited gatekeeping, and leaves follow-up care outside its scope entirely.

Emerging Evidence from Care Coordination Models

Against this backdrop, the presentation turns to emerging evidence, drawing on a systematic review of care coordination interventions from the South-East Asia region. Two broad building blocks recur across successful models: human resources for health, including nurse-led care, family physicians, multidisciplinary teams, and dedicated care coordinators; and digital and community infrastructure, including electronic health records, telehealth, SMS and IVR-based outreach, clinical decision support systems, and community health workers.

Two Indian examples illustrate what this looks like in practice. 

In a rural district of Tamil Nadu, the STEMI (ST-Elevation Myocardial Infarction) programme linked primary care centres, smaller hospitals, tertiary centres, and ambulances into a unified hub-and-spoke network, with ambulances transmitting real-time ECG and vital-sign data so cardiologists could maintain continuous oversight. The results were measurable. The share of patients receiving the more effective pharmaco-invasive therapy, rather than stand-alone thrombolysis, rose from 13 to 20%; a substantial share of rural poor patients, up to 60 %, were able to access the system through government insurance support; and the programme achieved an absolute four percentage-point reduction in mortality, a 20 % relative risk reduction.

In Karnataka, the telemedicine mentoring and monitoring programme took a different route to the same principle, integrating psychiatric care into primary health through a four-tier hub-and-spoke model: master trainers at an academic hospital hub, district psychiatrists at a mini-hub, primary care doctors at a micro-hub, and patients as the outermost spoke. District psychiatrists deliver live tele-mentoring and collaborative video consultations that train primary care doctors during actual patient encounters, transferring skill rather than just knowledge. The programme has reached over 20,000 patients to date, and of the general patients seen through tele-mentoring sessions, 32 %  were identified with a psychiatric disorder, a rate that falls within the expected range for primary care and signals that primary care providers, once supported, can meaningfully identify and manage mental illness themselves.

A triple win

Care coordination pays off for every actor in the system. For patients and families, it means earlier diagnosis, better identification and management of high-risk cases, working two-way referral pathways, continuous monitoring for treatment compliance, home-based care where appropriate, and reduced out-of-pocket expenditure. For providers, it means clearly defined roles, access to a patient's complete history, continuous and tailored communication with patients, and genuine inter-professional teamwork across specialists, doctors, lab technicians, pharmacists, nurses, and community health workers. For health systems, it means less overcrowding at secondary and tertiary facilities, better management of chronic and long-term illness, smoother transitions across facilities and from facility to home, less duplication of effort, and stronger linkages between primary and secondary care within insurance programmes.

Key takeaways for health systems leaders

• Treat care coordination as core infrastructure, not an optional layer. The evidence shows it is what converts scattered healthcare contacts into a continuum patients can actually experience as coherent care.
• Close the referral loop deliberately. Incomplete referral notes, self-reported follow-up, and undefined roles across multidisciplinary teams are recurring, fixable failure points, not inevitable ones.
• Invest in both people and digital infrastructure together. The strongest models, from Tamil Nadu's STEMI network to Karnataka's telepsychiatry programme, combine dedicated human roles with the digital rails that let those roles function across distance and time.
• Widen insurance design to match the continuum. Coverage that stops at the hospital door, as with PM-JAY's current inpatient-only scope, cannot support coordinated, longitudinal care for chronic and preventive needs.
• Measure the win on all three sides. A coordination model that helps patients but burdens providers, or helps providers but leaves health systems as overcrowded as before, has not yet closed the loop.

Ms. Singh's presentation makes the case for a care coordination infrastructure that is not assumed but built deliberately. It is what will determine whether India's primary health care system can hold together under the weight of the care journeys it is asked to support.