Coordination of care
This quick start guide complements the Pathways Community HUB Manual: A Guide To Identify and Address Risk Factors, Reduce Costs, and Improve Outcomes, published in 2016 by the Agency for Healthcare Research and Quality (AHRQ). That manual provides beginning tools and strategies for ensuring that individuals most at risk of poor health outcomes are served in a timely, coordinated manner.
The quick start guide is a reference and resource for public and private stakeholders engaged in...
The Health Research & Educational Trust (HRET) developed this compendium to link patient and family engagement concepts and strategies to available resources. The compendium resources are designed to support hospital efforts to partner with patients and families to improve health care quality.
The compendium includes the following sections:
- Organizational assessments
Patient and family advisory council/committee: resources for...
This library of publicly available resources and tools can help safety net providers understand and implement the patient-centered medical home (PCMH) model of care. Users can navigate these free resources by type or topic or by the registry of tools and resources, which includes all resources and tools hosted on the Web site and those hyperlinked within documents on the site.
Resource types include the following:
- PCMH assessment
- Change concept resources:...
This toolkit for hospitals provides information and resources to improve safety when newborns transition home from the neonatal intensive care unit (NICU). Through a Health Coach Program, the toolkit offers coaches, parents, and families information to coordinate care, understand signs and symptoms of illness, manage medicines and immunizations, manage breathing problems, and feeding.
This manual is designed to be customized and adapted for any institution that cares for fragile...
This guide for care managers and State Medicaid agencies provides information on how to use predictive modeling tools to identify patients who are good candidates for care management. A list of key considerations can help States prioritize and effectively target populations for care management, and help guide decisionmaking for patient care. The guide helps agencies do the following:
- Understand which features of a predictive model are critical as well as how to enhance...
This operational handbook for safety-net medical homes describes the experience of Doctors Care, a community-funded, nonprofit organization that helps underserved children, adults, and families receive the medical attention they need. The handbook can help program managers maximize health care for the uninsured without overwhelming participating doctors, while also managing patient expectations.
It is organized into the following sections:
- Doctors Care History:...
The Safety Net Accountable Care Organization (ACO) Readiness Assessment Tool is designed for the leaders in your organization (and whomever else that you wish) to assess how ready your organization is to take on the responsibilities of becoming an ACO serving your population of safety net patients.
The primary focus of the tool is on your organization’s capabilities to provide more coordinated, cost-effective, and high-quality care to your patients, whether you decide to become a...
Coordinated-Transitional Care (C-TraC) is a low-resource, telephone-based, protocol-driven program designed to reduce 30-day rehospitalizations and to improve care transitions during the early posthospital period. The goal of this toolkit is to help hospital systems that serve populations with high rates of patient dispersion, cognitive impairment, and vulnerability improve care coordination and postdischarge outcomes such as reduced medication discrepancies.
This toolkit is...
The HIV Care Coordination Tools resource page offers information, tools, and other educational materials for HIV-related health care, housing, and supportive service providers.
Resources include the following:
- Care coordination protocol and tools
- Provider pocket guide
- Patient workbook
- Fact sheet
- Client journal wallet card
Select materials are also available in Spanish....
The Primary Care–Specialty Care Compact was developed by the Systems of Care/Patient-Centered Medical Home Initiative, which seeks to improve systems of care by supporting physicians in becoming medical homes and working with specialists to uplink medical homes into integrated medical neighborhoods. The purpose of the compact is to improve care and build and sustain trusted medical neighborhoods through a defined communication protocol. It specifies key areas of a mutual care management...