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Community-based Care Coordination – A Comprehensive Development Toolkit
Community-based care coordination is a partnership among health care professionals, clinics and hospitals, specialists, pharmacists, mental health professionals, community services and other resources working together to provide patient-centered, coordinated care. Whether in the context of an accountable care organization (ACO), integrated health partnership (IHP), accountable communities for health (ACH), patient-centered medical home (PCMH), health care home (HCH) or other structure, the goals are the same: continually improve health care quality and patient experience while reducing overall costs.
The Community-based Care Coordination (CCC) Toolkit provides tools for use at different stages in the development of a CCC program—including how to begin a program. Tools focus on people, functions, policy, and processes to achieve success in the community-based care coordination environment.
Each tool includes:
The toolkit has three experience levels. Read through all the tools to understand how to develop or expand a community-based care coordination program.
Understand and determine your community’s current level of experience with various aspects of community-based care coordination, as well as its readiness to begin program development. Develop a strategy for advancing community-based care coordination based on for your community’s experience level. Complete lower levels tools before proceeding to the next higher level. Construct your own timeline based on the activities being undertaken. Each tool indicates how long it takes to implement.
The Overview section introduces you to the structure and navigation of the Community-based Care Coordination Toolkit, and provides tools that introduce basic concepts, terminology, and resources for community-based care coordination programs.View/Hide the Overview tools
The Assess section includes assessments and other tools to determine the readiness of a community to implement a community-based care coordination program. It also includes tools to help establish a steering committee that represents the community and to engage physicians.View/Hide the Assess tools
The Plan section tools lay out the components needed to implement a community-based care coordination program, from tips for understanding different reimbursement models for CCC programs to tools to help organize the work and program team.View/Hide the Plan tools
The Design section provides tools to help structure a community-based care coordination program, from staffing to patient cohort identification. Approaches emphasize patient communications.View/Hide the Select tools
The Implement tools help put the essential components of a community-based care coordination program into place. This may include workflow and process redesign. These tools help you begin operationalizing a program.View/Hide the Implement tools
The Maintain section provides tools to help evaluate effectiveness of the program. Monitoring goal achievement, celebrating success, correcting course where necessary, and preparing to optimize are key steps in maintaining a successful program.View/Hide the Maintain tools
The Optimize section provides tools to help communities implement more advanced components of a community-based care coordination program. The tools reflect new health care practices that support wellness and prevention, as well as illness and injury management. If your community has adopted a patient-centered medical home (PCMH) model, some of these practices may already be in place.View/Hide the Optimize tools
In an effort to continuously to improve the content and quality of the CCC Toolkit, we welcome your feedback. Please send your feedback for improvements to the toolkits to HITtoolkits@stratishealth.org.
tel: 952-854-3306 | toll-free: 1-877-STRATIS