Implementing Care Coordination

Core Value & Community Connections: A Guide to Care Coordination in the Medical Home (PCPCC, 2011)

This report offers best practices for evaluating care coordination and identifies new and emerging programs, and features three core elements: expert authored articles, case studies, and summaries of survey responses.

Coordinating Care in the Medical Neighborhood: Critical Components & Available Mechanisms (AHRQ, 2011)

This article introduces the concept of the PCMH in primary care and explores the mechanisms that the PCMH relys on to improve communication and coordination, including information sharing and clinician accountability.

Care Coordination Measuring Atlas (AHRQ, 2010)

This atlas helps evaluators identify appropriate measures for assessing care coordination interventions in research studies and demonstration projects, particularly those measures focusing on care coordination in ambulatory care.

Preferred Practices and Performance Measures for Reporting Care Coordination (NQF, 2010)

This document puts forth standards that provide the structure, process, and outcome measures required to assess progress toward care coordination goals and to evaluate access, continuity, communication, and tracking of patients across providers and settings.

Improving Hand-Offs and Transition of Care

The Care Transitions Program

This program aims to support patients and families, increase skills among health care providers, enhance the ability of HIT, implement systems-level interventions, develop performance measures and public reporting measures, and influence health policy at a national level.

The PCMH Neighbor: The Interface of the PCMH with Specialty/Subspecialty Practices (ACP, 2010)

This paper highlights the important role of specialty and subspecialty practices within the PCMH model, provides a framework to categorize interactions between PCMH and PCMH Nieghbor practices, and offers a set of principles for development, among other things.

Medication Management

Improving Patient Health Through Medication Management (PCPCC, 2012)

This resource guide was developed to provide a framework for integrating comprehensive medication management within the medical home as part of the practice redesign that needs to occur when individual and group practices transform into the medical home.

 

Back to Toolkit

Go to top