Improving Care Coordination Across the Medical Neighborhood

A Patient-Centered, Team-Based Approach

To effectively manage chronic conditions among patients in vulnerable communities, providers must utilize and optimize care teams that support patients through the cascade of care. Yet successful care teams collaborate not only within the health center, but also within patient communities. By incorporating community partners and stakeholders as part of the medical neighborhood, care teams can coordinate care that meets a patient’s needs in and outside of the provider’s office. The National Nurse-Led Care Consortium (NNCC) and the Washington Association for Community Health are convening a learning collaborative of health centers interested in enhancing care coordination efforts to improve clinical outcomes for patients. The learning collaborative is designed so that participants can bring lessons learned back to their health centers and train additional staff in care coordination and team based care optimization competencies. It is recommended that health centers bring a team including diverse roles to learn and plan together. A recommended iteration of a participating team includes 4 health center staff, including: 1) clinical director or provider; 2) medical assistant; 3) nursing staff member or care coordinator; and 4) clinical administrator or front desk supervisor.

MODULE 1: Introduction to Care Team Formation

• Presentation slides

• Webinar recording

MODULE 2: Framing Continuous Quality Improvement

• Presentation slides

• Case studies

MODULE 3: Improving Care Coordination across the Medical Neighborhood

• Presentation slides

• Case study activity

• Risk stratification activity

• SDOH tools

• SDOH coding and documentation

• Trauma-Informed Care for staff

1. Communication

• Communication Part 1: ​Communicating Effectively

• Communication Part 2: Patient Communication & Engagement

• SBAR & huddle checklist

• Additional resources

2. Role & Role Optimization

• Role and Role Optimization Part 1: Defining Team Roles and Responsibilities

• Role and Role Optimization Part 2: Role Optimization Tools

• Swim lane and sample job description

• Additional resources

3. Care Coordination

• Care Coordination Part 1: Care Coordination Definitions

• Care Coordination Part 2: Medical Neighborhood

• Risk stratification

• Patient transfer form

• Additional resources

Case Studies

• Core Principles & Values of Effective Team-Based Health Care

• Collaboration in Practice: Implementing Team-Based Care

• Quick Reference Guide to Promising Care Models for Patients with Complex Needs

• Building Teams in Primary Care: 15 Case Studies

​MODULE 4: Follow Up and Peer Learning

• Presentation slides

• Discussion Forum