Health Care Homes
Learning Collaborative
Fundamentals of Care Coordination - Resources

Introduction to Care Coordination

Quadruple Aim

• From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider | Annals of Family Medicine (AFM)

Treat High-need, High-cost Patients

• Attributes Common to Programs That Successfully Treat High-Need, High-Cost Individual (AJMC)

Triple Aim

• The Institute for Healthcare Improvement Triple Aim (IHI)

The Care Coordinator

Assessing Your Needs

• Community Health Assessment (MDH)
• Emotional Intelligence in the Nursing Profession (ASRN)
• Organized, Evidence-Based Care: Planning Care for Individual Patients and Whole Populations (Qualis Health) (PDF)
• Six Seconds Emotional Intelligence Assessment - Measure and improve emotional intelligence (SEI)
• STAR Interviewing Model for Behavioral Interview Questions (careerprofiles.info)

Quality Improvement and the Care Coordinator

• Improving Primary Care (AHRQ)
• Measuring Care Coordination in Medical Homes (Commonwealth Fund)
• Model for Improvement (IHI) 

Recognizing and Preventing Care Coordinator Burnout

• Framework for Improving Joy in Work (IHI)
• Support Staff with Flexible Working (NHS)

TeleHealth

• A better model for care — virtual care coordination (NCBI)

What is a Care Coordinator?

• Understanding Healing Relationships in Primary Care (AFM)

Where to Find a Care Coordinator

• Health Care Workforce Reports (MDH)
• PIPELINE DUAL TRAINING GRANTS (DLI)

Defining Care Coordination

Managing Care Transitions

• A Resource Guide: Information, Strategies, and Tools for Managing Care Transitions (Care Providers) (PDF)
• Managing Transitions with a Pediatric Population (Got Transition)

Patient Centered Care

• Advancing the Practice of Patient and Family - Centered Care in Primary Care and Other Ambulatory Settings, How to Get Started (IPFCC) (PDF)
• Advancing the Practice and Understanding of Patient- and Family-Centered Care (IPFCC)
• HCH Patient and Family Centered Care Resources (MDH)
• Overview of Care That is Person & Family Centered (PCPCC)
• Implementation Guide, Patient-Centered Interactions (SNFI) (PDF)
• Eliciting the Patient’s Perspective (SNFI) (PDF)
• The Patient-Centered Medical Home from the Patient’s Perspective (SNFI) (PDF)

Patient Engagement and Activation

• A Collection of Tools and Strategies to Increase Patient Health Literacy (AHRQ)
• Guide to Implementing the Health Literacy Universal Precautions Toolkit (AHRQ)
• Guide to Strengthening Patient Engagement in Their Care (AHRQ)
• Overview of Health Literacy with Links to Resources (CDC)

Team Based Workflows

• Functions of the Medical Home: Comprehensive, Team-Based Approach to Care (AHRQ)
• Health Care System Redesign (AHRQ)
• Improving the Care Team’s Performance and Enhancing Patient Safety (AHRQ)
• Information and Resources for Building and Sustaining Effective Care Teams (AHRQ)
• Research - Examining the Perspective of Care Coordinators in Patient-Centered Medical Homes on Their Role (NCBI)

Resources for Care Coordination

Behavioral Health, Tools and Strategies for Care Coordinators

• National Alliance on Mental Illness Minnesota - Locate Services and Support for Patients (NAMI)
• Mental Health Minnesota - Information, Fact sheets, and Worksheets to Assist Individuals in Developing a Healthy Lifestyle as a Support for Mental Health (Mental Health MN)
• Mental Health by the Numbers (NAMI)
• Depression in Older Adults (NIA NIH)
• Authoritative Information about Mental Disorders (NIMH)

Community Partnerships

• Information on and Insight Into How to Build Community-Healthcare Partnerships (AHA) (PDF)
• Using Community Partnerships to Integrate Health and Social Services for High-Need, High-Cost Patients (Commonwealth Fund)
• Making Community Partnerships Work: A Toolkit / March of Dimes (AAPCHO) (PDF)

Cultural Competence

• Cultural Responsiveness (Cultural Care Connection)
• Culture Care Connection - Information, Tools, and Resources Supporting the Delivery of Culturally Competent Care (Stratis)
• Georgetown University: Cultural and Linguistic Competence (NCCC)
• Health Resources and Services Administration (HRSA)
• Positive Youth Development Resources (OASH)
• National Resource Center for Patient/Family-Centered Medical Home, a national technical assistance center (AAP)
• Practical Strategies for Culturally Competent Evaluation (CDC) (PDF)

Literacy Learning

• Literacy Learning Barriers (Mini-Cog)

Motivational Interviewing and Coaching

• Examples of Motivational Interviewing Techniques to Support Behavior Change in Patients With Multiple Chronic Conditions (Lake Superior QIN)
• Training Video (MINT)

Shared Decision Making and SMART Goals

• Description of SMART Goals, Including Tools and Resources for Writing and Using Them (MDH)
• The SHARE Approach - Putting Shared Decisionmaking into Practice - Five “Essential” Steps (AHRQ)
• Shared Care Planning and Coordination for Long-Term and Post-Acute Care (CAST) (PDF)
• Enhancing Patient Engagement through Shared Decision-Making (NQF)
• Minnesota Shared Decision-Making Collaborative - Multi-Stakeholder Community Learning Collaborative - Shared Decision-Making in Clinical Practice throughout Minnesota (MSDMC)
• A Guide For S.M.A.R.T Goal Setting (ACE)
• The Essential Guide to Writing SMART Goals (Smartsheet)
• 5 Steps to Setting Smart Goals (Smart-goals-guide)
• Overview of Objectives, How to Write SMART Objectives, a SMART Objectives Checklist, and Examples of SMART objectives (CDC) (PDF)

Social Determinants of Health

• PRAPARE Implementation and Action Toolkit - A Resource for Gathering, Assessing, and Responding to Data on the Social Determinants of Health (NACHC)
• Overview of SDOH and how some healthcare organizations are addressing them (NEJM)

Trauma Informed Care

• Trauma-informed Health Care - CTHC at UCSF
• Key Ingredients for Successful Trauma-Informed Care Implementation (CHCS) (PDF)
• Strategies for Encouraging Staff Wellness in Trauma-Informed Organizations (CHCS)(PDF)

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