Community-based care coordination is a partnership among health care professionals, clinics and hospitals, specialists, pharmacists, mental health professionals, community services and others 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 health care 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 patient-centered and community-based health and wellness
  • 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 managing 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. 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

Overview

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

 

The overview section provides an introduction 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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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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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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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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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 begin operationalization of a program.

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Maintain

The maintain section provides tools to help evaluate effectiveness of the program, including 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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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. Communities that have adopted a patient-centered medical home (PCMH) model may already have these practices in place.

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