Reducing Care Fragmentation: A Toolkit For Coordinating Care


Reducing Care Fragmentation: A Toolkit For Coordinating Care


This toolkit has been designed for patient-centered medical homes aiming to transform how their clinics manage patient referrals and transitions, and its goal is to provide clinical practice resources to support coordinated care. The toolkit introduces four key concepts for enabling change, and offers activities, tools, and case studies to support their implementation.

The toolkit is divided into the following sections:

  • Introduction
  • The care coordination model
  • Change package and tools
    • Key change/activities table
    • Accountability
    • Patient support
    • Relationships and agreements
    • Connectivity
  • Case studies
  • Tools and resources


MacColl Institute for Healthcare Innovation

Funding Sources:

Commonwealth Fund


Release Date: 2011
Original Summary: July 2011
Last Updated: 07/20/11

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