Coordinating Care in a Fragmented System

This database is no longer actively maintained and is here for archival purposes only

Organization Type: 
For Profit
Program Type: 
Standing Program
Education Level: 
Continuing Education
Educational Elements: 
Independent Study
Self Reflection Activities
Experiential not including services to patients
Program Description: 

This training program helps health professionals tackle population health management.  This new model of care will require that nurses and other health care personnel acquire the knowledge and skills necessary to move from an episodic orientation to a population health model.  This course is designed around three essential elements in population health management: managing high risk patients, managing chronic illnesses, and managing transitions in care.  Skills required to achieve these goals include, but are not limited to: coaching, empowerment, motivating behavior change, advocacy, and adult learning principles.  Legal and ethical issues are discussed, and the course culminates with a discussion of future models and the role of nurses and other health personnel in creating new roles for the future. 

At the end of this course the student will be able to:

  1. Describe the transformation in health care delivery from episodic care to population health management and the impact on patient care
  2. Identify new roles for nurses and other health care personnel in population health management
  3. Analyze interventions specific for high risk patients in population health management
  4. Analyze interventions specific for chronically ill patients in population health management
  5. Discuss issues related to patient transitions to home care
  6. Propose strategies for managing clinical outcomes in a diverse population
  7. Analyze legal and ethical issues related to population health management
  8. Describe emerging trends in population health management and future roles for nurses and other health care personnel
Targeted Professions
Registered Nurses
Licensed Practical Nurses
Social Work: 
Medical social work
Self-Reported Competencies
PCPCC’s Education and Training Task Force identified 16 interprofessional training competencies critical for preparing health professionals for practicing in team-based, coordinated care models such as patient-centered medical homes. Listed below are the self-reported competencies that this program has achieved, which have been organized by the five core features of a medical home as defined by the Agency for Healthcare Research and Quality
Patient-Centered Care Competencies: 
Advocacy for patient-centered integrated care
Cultural sensitivity and competence in culturally appropriate practice
Development of effective, caring relationships with patients
Patient-centered care planning, including collaborative decision-making and patient self-management
Comprehensive Care Competencies: 
Population-based approaches to health care delivery
Coordinated Care Competencies: 
Care coordination for comprehensive care of patient & family in the community
Health information technology, including e-communications with patients & other providers
Interprofessionalism & interdisciplinary team collaboration
Quality Care & Safety Competencies: 
Assessment of patient outcomes
Evidence-based practice
Quality improvement methods, including assessment of patient-experience for use in practice-based improvement efforts
Last updated July 21, 2014

* Please note: Information contained in this database is self-reported by representatives from each program. It does not represent an exhaustive list of education and training programs and inclusion does not constitute an endorsement from the PCPCC.


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