Medical Home Practice-Based Care Coordination

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Medical Home Practice-Based Care Coordination:

A Workbook By:
Jeanne W. McAllister Elizabeth Presler W. Carl Cooley

Center for Medical Home Improvement (CMHI) Crotched Mountain Foundation & Rehabilitation Center; Greenfield, New Hampshire

Beyond the Medical Home: Cultivating Communities of Support for Children/Youth with Special Health Care Needs Funded by: H02MC02613-01-00 United States Maternal and Child Health Bureau, Integrated Services for CSHCN, HRSA June 2007

Workbook Contents This workbook includes the tools and supports needed for a primary care practice to develop their capacity to offer a pediatric care coordination service; particularly for children with special health care needs. The health care team, determined to develop such an explicit service, makes an assessment of current care coordination practice and frames their improvement efforts to achieve proactive comprehensive practice-based care coordination. Tools included in this resource are: a definition of care coordination in the medical home, a care coordination position description, a framework for care coordination services including structures and processes, strategies for the protection of devoted staff time, and a logical sequence of care coordination improvement ideas offered in the context of the Model for Improvement (Langley, 1996). Each tool can be used as is or it can be customized in a manner which best fits your practice environment and the strategic plans your organization holds for medical home improvement activities. Table of Contents Medical Home Practice Based Care Coordination Medical Home Care Coordination A Definition & A Vision Is It Medical Home Care Coordination? A Checklist Medical Home (Practice Based) Care Coordination - Position Description - A Worksheet A Medical Home (MH) Care Coordination Framework - Framework - Worksheet Time Protection Tips & Strategies ……………………………….3

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………………………………9 ……………………………..10 ……………………………...11

Care Coordination Development: The Model for Improvement ………………………………12 Care Coordination Aim Statement ………………………………13 Care Coordination Outcomes ………………………………14 Plan Do Study Act (PDSA) Worksheet & Examples ………………………………15 1) Care Coordination Role/System ………………………………16 2) Care Coordination – Needs Assessment ………………………………18 3) Comprehensive Care Planning ………………………………20 Medical Summary, Action & Emergency Plans 4) Transition to Adult Care & Services ………………………………22 5) Community Outreach & Resources ………………………………24 Appendices A. Websites and References …………………………..…..26 2

Medical Home - Practice-Based Care Coordination
This workbook is designed to support practice-based quality improvement teams in their efforts to build comprehensive primary care “medical homes”. The focus is specifically upon the professional role development for the provision of practice-based care coordination. The ideal care scenario is one where the staff within the medical home is proactively prepared to support the central care giving role of families. The role of care coordination discussed within this workbook is one designed in the service of children/youth with special health care needs (CYSHCN). It is acknowledged that care coordinators in different environments will apply their skills and efforts toward the care of all children as well as adults with special needs or chronic health conditions; you should find the structures and processes offered within suitably applicable. Workbook Goals and Objectives: Goal: To put forth a practice-based medical home care coordination framework from which practices can select and suitably customize. Contents include a medical home care coordination checklist, definition, position description, model framework with structures and processes, and strategies for effective and successful care coordination development and implementation. Objectives: 1) Define practice-based care coordination for children with special...
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