Care Coordination Burden Snapshot
A 15-question scored look at the coordination load on your household — and how exposed you'd be if something changed tomorrow.
Already enrolled in a care management program?
If your loved one is on Chronic Care Management (CCM), Remote Patient Monitoring (RPM), GUIDE, Principal Illness Navigation, or a similar program through their provider — those programs identify clinical needs and stay in regular contact.
This snapshot measures something different: whether your household has the capacity to act on what the program is identifying. Records, scheduling, vendors, transportation, resource activation, and family alignment all happen outside the clinical workflow — and usually fall on one family member. The two work together, not against each other.
Answer 15 questions. There are no clinical questions. Each scores 0, 1, or 2 based on what fits your household. The first four sections measure burden today; the last measures exposure and readiness if something changed. Takes about 4 minutes. Free, anonymous, no signup required to take the snapshot.
1 Care complexity
How many providers and open loops are in play right now.
1 How many active providers or services are involved right now?
PCP, specialists, home health, therapy, DME, pharmacy, etc.
2 Are there unresolved referrals, orders, appointments, records, or pharmacy issues?
2 Household support
How help with daily activities, household services, and vendors is being managed.
3 Does help with daily activities (bathing, dressing, mobility, personal care) need attention?
4 Who is managing meals, transport, supplies, medication pickup, and vendors?
3 Family operator
Who is acting as the unpaid project manager, and how reachable they are.
5 Is one family member acting as the unpaid project manager?
6 Is the key family operator local and reachable during business hours?
7 Is a spouse or other household member also in CCM, RPM, GUIDE, PIN, home health, or similar?
4 Execution and overload
Whether recommended resources have actually started, transitions are ahead, and the household is keeping up.
8 Has a resource, service, or support been recommended but never actually started?
Transport, meals, pharmacy delivery, home health, DME, respite, caregiver support, etc.
9 Has there been a recent or upcoming transition?
Hospital, SNF, ED, surgery, home health start, new PCP.
10 Do you want someone to actually handle coordination — not just provide phone numbers?
Includes the calls, reminders, portals, and repeated explanations that wear families down.
5 Exposure & readiness
Not how busy things are today — how exposed your household would be if something changed tomorrow.
11 If you went to the ER tomorrow, who knows your specialists, medications, and care decisions well enough to brief the team?
A signed healthcare POA names someone — but the named person often does not know your doctors or your medications.
12 Who is in the household, and is there local family who would actually show up?
13 Are health records and care history curated anywhere outside provider portals?
14 Could anyone else reconstruct what's been tried, what failed, and what you'd refuse?
Medication reactions, past treatments that didn't work, nuanced care preferences beyond a basic directive.
15 Who actually handles the next round of paperwork, scheduling, and vendor coordination?