The present invention discloses substantially more efficient and effective methods for delivering healthcare whereby patient care can be coordinated effectively and efficiently through changes in different physical settings and levels of care. Coordinated care helps ensure that patients seeking healthcare, and in particular chronically ill patients, with comorbidities get timely care to avoid unnecessary emergency room visits and admissions. Through risk and disease stratification, member profiling, inter disciplinary team follow-up and patient education, the methods of the present invention are operative to effectively allocate available resources, formulate and execute individualized care plans and successfully manage high risk members.