Medical Home Practice-Based Care Coordination Workbook


Medical Home Practice-Based Care Coordination Workbook


The Medical Home Practice-Based Care Coordination Workbook includes the tools and supports needed for a primary care practice to develop its capacity to offer a pediatric care coordination service, particularly for children with special health care needs.

The workbook goals and objectives are as follows:

  • 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 health care needs in a medical home
    2. Select and appropriately modify a position description that fits each unique medical home improvement team environment
    3. Use a care coordination model framework to fit the role well within each practice environment
    4. Draw from a list of time protection and resource allocation strategies those with the best fit for the practice environment and related improvements
    5. Develop tests of change (PDSA - plan, do, study, act) for the incremental development of a comprehensive care coordination service model to include: care services, assessment of needs, care planning, transition support, and community outreach with resource linkages


Center for Medical Home Improvement

Funding Sources:

Health Resources and Services Administration, Maternal and Child Health Bureau


Release Date: 2007
Original Summary: March 2010
Last Updated: 03/31/10

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