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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.
In building or expanding a community-based care coordination program, members of a healthcare community seek to:

  • Engage with community partners as an integral part of a holistic approach to patient care
  • Transform care delivery from provider-centric, episodic care to a patient-centered and community-based health and wellness focus
  • Provide active management of transitions-in-care and tracking of referrals to help ensure a closed loop of information
  • Reduce the burden on providers by supporting patients in actively manage their health conditions through patient engagement and education

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:

  • Brief statement of purpose – know why and when to use each tool
  • Instructions for use – a guide for effective use of each tool
  • Option to customize – customize tools for your own needs and to help you perform tasks

Getting Started

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.

Experience Level

easy - level 1 Level 1: For all organizations.
intermediate - level 2 Level 2: For organizations with more resources.
difficult - level 3 Level 3: For organizations interested in advanced topics.

Overview

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.

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# Tool Use Purpose Experience Level
1 How to Use the CCC Toolkit This document describes the tools in the CCC Toolkit and how the Toolkit is organized. (6-page PDF) Inform 1easy - level 11
2 Table of Contents for CCC Toolkit This document lists and briefly describes all the tools in the CCC Toolkit in alphabetic order. (6-page PDF) Inform 1easy - level 11
3 CCC Program Workflow Diagram This tool provides a pictorial view of CCC program development, including processes and workflows by phase. (6-page PDF) Inform 1easy - level 11
4 CCC Program Workflow and Tools This tool provides a brief overview of each phase in CCC program development, along with a process flow diagram and a list of tools that support the processes in each phase. (9-page PDF) Inform 1easy - level 11
5 Glossary of Terms for CCC This document provides definitions of commonly-used terms in the context of a community-based care coordination (CCC) program. (11-page PDF) Inform 1easy - level 11

1. Assess

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.

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# Tool Use Purpose Experience Level
1 Steering Committee for CCC This tool provides strategies for establishing and managing a steering committee for a CCC program, and provides sample meeting agenda and minutes. (7-page PDF) Inform 1easy - level 11
2 Community Data Collection Form This tool is a template to facilitate collection of community data as part of an initial assessment for planning and developing a CCC program. (18-page Word doc) Action 2intermediate - level 22
3 CCC Maturity Assessment This tool identifies a number of attributes associated with four levels of CCC program maturity. (5-page PDF) Inform 1easy - level 11
3.1 CCC Maturity Assessment Template This tool is a template for use with the CCC Maturity Assessment. (5-page Word doc) Action 1easy - level 11
3.2 CCC Maturity Assessment Example and Report This tool shows an example of a completed CCC Maturity Assessment and Report. (6-page PDF) Action 1easy - level 11
3.3 CCC Maturity Assessment - Example Program Comparison Report This tool shows an example report comparing the CCC Maturity Assessment results from two or more CCC programs. (2-page PDF) Action 2intermediate - level 22
4 Physician Engagement in CCC This tool describes the importance of engaging physicians in a CCC program and provides a framework for physician engagement in CCC program planning. (6-page PDF) Inform 1easy - level 11
4.1 Physician Engagement Difficulty Assessment Template This tool is a template for use with Physician Engagement in CCC. (2-page pdf) Action 2intermediate - level 22
5 CCC Fact Sheet for Providers This document provides “Ten Facts Providers Need to Know about Community-based Care Coordination” for use in engaging physicians in CCC program planning and implementation. (2-page PDF) Inform 1easy - level 11

2. Plan

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.

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# Tool Use Purpose Experience Level
1 CCC Governance This tool provides guidelines for planning an effective governance structure for a CCC program. (6-page PDF) Inform 1easy - level 11
2 Setting and Monitoring Goals for CCC This tool describes the importance of setting goals for a CCC program and monitoring results toward achievement of the goals. (7-page PDF) Action 1easy - level 11
3 Business and Reimbursement Models for CCC This tool provides an overview of reimbursement models, and includes tools and resources to support development of new business model(s) being contemplated. (7-page PDF) Inform 2intermediate - level 22
4 CCC Program Staffing Models This tool helps determine the type and level of staffing required for care coordination functions to be performed within a CCC program. (6-page PDF) Action 2intermediate - level 22
5 Care Coordination Roles Planning Matrix The tool helps the program leadership understand the various roles to be performed within a CCC program, and determine who is responsible for each activity. (4-page PDF) Inform 2intermediate - level 22
5.1 Care Coordination Roles Planning Template This tool is a template for use with the Care Coordination Roles Planning Matrix. (4-page Word doc) Action 2intermediate - level 22
6 CCC Program Project Plan This tool outlines the general sequence of activities required to implement a CCC program. (6-page PDF) Inform 1easy - level 11
6.1 CCC Program Project Plan Template This tool is a template for use with the CCC Program Project Plan. (1-worksheet Excel spreadsheet) Action 1easy - level 11
7 CCC Program Change Management This tool provides an overview of CCC program change management, focusing on challenges and opportunities for program change, stages and agents of change, and conflict resolution. (12-page PDF) Inform 1easy - level 11
8 Communication Plan This tool describes the use of a communication plan to support the CCC program, and describes how to construct and manage a communication plan. (7-page PDF) Inform 2intermediate - level 22
8.1 Communication Plan Template This tool is a template for use with the Communication Plan. (2-page Word doc) Action 1easy - level 11
9 Issues Log Example and Template This tool provides an example and template for capturing and managing program issues, for use with Steering Committee for CCC and CCC Program Project Plan. (2-page Word doc) Action 1easy - level 11
10 Meeting Agenda and Minutes Template This tool provides a template for preparing a meeting agenda and minutes, for use with Steering Committee for CCC and CCC Program Project Plan. (1-page Word doc) Action 1easy - level 11

3. Design

The Design section provides tools to help structure a community-based care coordination program, from staffing to patient cohort identification. Approaches emphasize patient communications.

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# Tool Use Purpose Experience Level
1 Care Coordinator Sample Job Description This tool provides a sample job description for a care coordinator (CC) serving in a community-based care coordination (CCC) program. (4-page PDF) Inform 1easy - level 11
2 Resource Checklist for CCC This tool identifies the resources a community needs to set up a CCC program and helps identify those that are in place or are needed to be built or procured. (6-page PDF) Inform 1easy - level 11
3 Population Risk Stratification and Patient Cohort Identification This tool provides an overview of population risk stratification and a process to identify specific patients to be served by the CCC program. (8-page PDF) Action 2intermediate - level 22
4 Assessment of Data Needs for Clinical Quality Measures (CQMs) This tool introduces clinical quality measures (CQMs) for evaluating quality outcomes, and provides guidance for monitoring quality outcomes and assessing progress toward CCC program goals. (5-page PDF) Inform 2intermediate - level 22
5 Establishing the Care Team: Roles and Communications This tool describes the roles of healthcare professionals in a CCC program, and provide resources to facilitate team communication and collaboration. (11-page PDF) Inform 1easy - level 11
6 Workflow and Process Analysis for CCC This tool introduces workflow and process improvement, describes the value of workflow and process analysis to initiate changes necessary for a CCC program, and provides instruction on workflow and process mapping. (11-page PDF) Inform 2intermediate - level 22
6.1 Workflow Process Chart Template This tool is a template for use with Workflow and Process Analysis for CCC. (2-page Word doc) Action 2intermediate - level 22
7 Technology Tools and Optimization for CCC This tool describes a variety of health information and technology tools and how they may be optimally used to support a CCC program. (12-page PDF) Inform 1easy - level 11
8 Approaches to Patient Communications This tool identifies the types of communications a care coordinator will have with patients in a CCC program, and provides links to tools that help in conducting and documenting patient communications. (11-page PDF) Inform 1easy - level 11
9 Introduction to Clinical Guidelines This tool describes the use of evidence-based guidelines and provides a plan for implementing them in a CCC program. (8-page PDF) Inform 1easy - level 11

4. Implement

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.

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# Tool Use Purpose Experience Level
1 Provider Resource Directory This tool supports the identification of different types of providers to help patients with specific health care needs, and helps establish working relationships and agreements with those providers. (7-page PDF) Inform 1easy - level 11
1.1 Provider Resource Directory Template This tool is a template for use with Provider Resource Directory. (3-page Word doc) Action 1easy - level 11
2 Community Resource Directory This tool supports the identification and use of a variety of community resources to help patients with healthcare-related needs. (6-page PDF) Inform 1easy - level 11
2.1 Community Resource Directory Template This tool is a template for use with Community Resource Directory. (3-page Word doc) Action 1easy - level 11
3 Business Associate and Other Agreements This tool identifies the types of agreements that may be necessary for a CCC program to have in place to provide access to or exchange data among participants in the program and with vendors. (13-page PDF) Inform 2intermediate - level 22
4 Authorization Form Template This tool is a template form to facilitate patient authorization to share PHI, for use with Business Associate & Other Agreements. (2-page Word doc) Action 2intermediate - level 22
5 Referral Tracking and Follow-up This tool describes tracking and follow-up on patient referrals within a CCC program, and suggests tools to manage patient referrals. (8-page PDF) Inform 1easy - level 11
5.1 Patient Visit Agenda and Preparation Checklist Template This tool is a template for a patient visit agenda and patient visit preparation checklist, for use with Referral Tracking and Follow-Up and Patient-Provider Agenda. (2-page Word doc) Action 2intermediate - level 22
6 Documentation for CCC Reimbursement This tool describes the documentation and potential workflow changes needed for reimbursement of transitional care management (TCM), chronic care management (CCM), and community-based care coordination (CCC) services. (5-page PDF) Inform 3difficult - level 33
6.1 Documentation for CCC Reimbursement Template This tool is a template for use with Documentation for CCC Reimbursement. (2-page Word doc) Action 3difficult - level 33
7 Patient Empanelment This tool describes the process and considerations for assigning each provider a set of patients to be cared for by that provider (and provider’s care team) to ensure continuity of care. (7-page PDF) Inform 2intermediate - level 22
8 Patient Care Coordination Variance Reporting This tool describes variances in patient care coordination, and provides suggestions for documenting and reporting on variances. (9-page PDF) Inform 1easy - level 11
8.1 Patient CC Variance Reporting Log Template This tool is a template for use with Patient CC Variance Reporting. (3-page Word doc) Action 1easy - level 11
8.2 Patient CC Variance Reports Template This tool is a template for use with Patient CC Variance Reporting. (4-page Word doc) Action 1easy - level 11
9 Pharmacist Outreach This tool helps establish a pharmacist outreach program to assist with medication management and coordination in the home setting. (6-page PDF) Inform 2intermediate - level 22
10 CCC Patient Plan This tool provides an overview of the community-based care coordination (CCC) patient plan for use in planning for and tracking CCC program services for a patient. (5-page PDF) Inform 1easy - level 11
10.1 CCC Patient Plan Template This tool is a template for use with CCC Patient Plan. (4-page Word doc) Action 1easy - level 11
11 Patient Action Plan This tool provides an overview of the Patient Action Plan, a patient engagement tool to support management of patient-specific health conditions. (8-page PDF) Inform 1easy - level 11
11.1 Patient Action Plan Template This tool is a template for use with Patient Action Plan. (9-page Word doc) Action 1easy - level 11
12 Care Coordination Task Plan and Weekly Schedule This tool identifies the types of tasks that a care coordinator might perform in a given week, and provides an example schedule and approach to planning weekly care coordination tasks. (6-page PDF) Action 2intermediate - level 22
13 Patient Recruitment This tool describes the general approach and strategies to recruit (invite) patients to participate in the community-based care coordination (CCC) program. (5-page PDF) Inform 1easy - level 11
14 Supportive Communications This tool describes a technique to invoke a desire for change in patients to make modifications to their lifestyles that will improve their health and wellness. (7-page PDF) Inform 1easy - level 11
15 Promoting Patient Self-Management This tool provides a conceptual overview of patient self-management and describes steps to initiate patient self-management. For techniques and example scripts for engaging patients in self-management, see Coaching Patients in Self-Management. (4-page PDF) Inform 3difficult - level 33
16 Patient Discharge Care Coordination Checklist This tool provides a list of steps that the care coordinator should follow to ensure that a patient will be supported upon discharge from the hospital or ED. (2-page PDF) Action 1easy - level 11
17 Health Risk Assessments This tool describes various health risk assessments to help understand potential barriers to meeting a patient’s health care goals. A template for each assessment instrument is included in this Toolkit. (24-page PDF) Inform 3difficult - level 33
17.1 Depression Risk Assessment Template This tool is a template for assessing depression risk, for use with Health Risk Assessments. (2-page PDF) Action 3difficult - level 33
17.2 Digital Literacy Assessment Template This tool is a template for assessing digital literacy, for use with Health Risk Assessments. (2-page Word doc) Action 3difficult - level 33
17.3 Environmental Risk Assessment Template This tool is a template for assessing environmental risks, for use with Health Risk Assessments. (2-page Word doc) Action 3difficult - level 33
17.4 Fall Risk Assessment Template This tool is a template for assessing fall risks, for use with Health Risk Assessments. (3-page Word doc) Action 3difficult - level 33
17.5 Functional Risk Assessment Template This tool is a template for assessing functional status and risks, for use with Health Risk Assessments. (2-page Word doc) Action 3difficult - level 33
17.6 Health Literacy Assessment Template This tool is a template for assessing health literacy, for use with Health Risk Assessments. (3-page Word doc) Action 3difficult - level 33
17.7 Medication Reconciliation Template This tool is a template for addressing medication reconciliation, for use with Health Risk Assessments. (2-page Word doc) Action 3difficult - level 33
17.8 Social and Financial Risk Assessment Template This tool is a template for assessing social and financial risks, for use with Health Risk Assessments. (2-page Word doc) Action 3difficult - level 33
17.9 Substance Use Risk Assessment Template This tool is a template for assessing substance use and risks, for use with Health Risk Assessments. (2-page Word doc) Action 3difficult - level 33
18 Health and Wellness Preventive Services This tool provides tips for improving use of preventive services among patients in a CCC program, and information on automated reminder systems. (6-page PDF) Inform 1easy - level 11
19 Workflow and Process Redesign for CCC This tool provides the “second step” following workflow and process analysis, and includes instructions for identifying processes needing improvement, determining the root cause of the problem, and redesigning and testing the improved process. (7-page PDF) Action 3difficult - level 33

5. Maintain

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.

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# Tool Use Purpose Experience Level
1 Quality Scores Monitoring and Reporting This tool describes potential quality measurement and performance requirements for a CCC program, the process of quality measure reporting, and ongoing monitoring of quality scores. (9-page PDF) Inform 2intermediate - level 22
2 CCC Program Satisfaction Surveys This tool provides sample survey tools that can be used to assess patient, provider, and CCC program/system staff satisfaction with CCC services. (10-page PDF) Inform 2intermediate - level 22
2.1 CCC Program Satisfaction Survey Template This tool is a template for a satisfaction survey of CCC program participants, for use with CCC Program Satisfaction Surveys. (2-page Word doc) Action 2intermediate - level 22
2.2 Patient CCC Satisfaction Survey Template This tool is a template for a patient satisfaction survey, for use with CCC Program Satisfaction Surveys. (2-page Word doc) Action 2intermediate - level 22
2.3 Provider CCC Satisfaction Survey Template This tool is a template for a provider satisfaction survey, for use with CCC Program Satisfaction Surveys. (2-page Word doc) Action 2intermediate - level 22
3 CCC Program Evaluation This tool provides CCC program leadership with tools to evaluate both processes and outcomes of the program. (9-page PDF) Action 2intermediate - level 22

6. Optimize

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.

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# Tool Use Purpose Experience Level
1 Shared Decision Making This tool describes how to encourage patients to participate in an informed dialogue with their providers to help them make healthcare decisions that best align with their values, preferences, and lifestyle. (5-page PDF) Inform 2intermediate - level 22
2 Coaching Patients in Self-Management This tool provides techniques and example scripts to encourage patient engagement in self-management. For an overview of patient self-management concepts, see Promoting Patient Self-Management. (9-page PDF) Inform 3difficult - level 33
3 Patient Health Diary This tool describes how a patient health diary can help patients, care coordinator, and providers keep track of a patient’s health status and recognize when there are health issues to be addressed. (6-page PDF) Inform 2intermediate - level 22
4 Patient-Provider Agenda This tool describes the benefits of a visit agenda to both patients and providers, and suggests steps to implement a patient-provider agenda. (7-page PDF) Inform 2intermediate - level 22
5 Remote Patient Monitoring This tool describes the nature of remote patient monitoring devices and offers recommendations on how to implement remote patient monitoring within a CCC program. (9-page PDF) Inform 3difficult - level 33
6 Personal Health Record This tool provides information about the personal health record (PHR) to support patient communication with providers and in self-management. (8-page PDF) Inform 3difficult - level 33
7 Making Smart Referrals This tool helps the care coordinator (CC) and providers understand how to make appropriate referrals for specialty healthcare or community resources for patients. (4-page PDF) Action 2intermediate - level 22
8 Open Access This tool provides information about implementing a scheduling system that reduces long wait times and appointment backlogs. (6-page PDF) Inform 3difficult - level 33
9 Workflow and Process Optimization for CCC This tool provides the “third step” following workflow and process analysis and redesign to help the CCC program team adopt more advanced components of CCC. (5-page PDF) Action 3difficult - level 33

Feedback Welcome

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.