Tools for Coordinating Care: Toolkits and Guides

This section provides tools to assist in the coordination of care at the practice, community, and state level.

Medical Home Practice-Based Care Coordination Workbook, June 2007
Published by the Center for Medical Home Improvement (CMHI) with an aim to develop, implement and evaluate care coordination in a medical home as part of an improvement process.

2006 Care Coordination Toolkit
WHAT's NEW: includes vignettes for the new care plan oversight codes, information on non-physician care coordination provider codes.
Description: Proper Use of Coordination of Care Codes with Children with Special Health Care Needs (CSHCN). This toolkit provides information on billing for the coordination of care with descriptions of individual codes, proper documentation, and an easy to follow billing slip for physician and non-physician time. Developed by the Center for Infants and Children with Special Needs at Cincinnati Children’s Hospital Medical Center & The National Center of Medical Home Initiatives for Children with Special Needs.

Appendices Included:

1. Identification of CYSHCN: Tools and Strategies
   How to Label / Flag the Chart: Tools and Strategies
2. Forms
3. How to Negotiate with Public and Private Insurers: Tools and Strategies
4. Selected Vignettes

Forms from the toolkit are available in word and excel formats

• Physician Management Billing Form
• Care Coordination Measurement Tool
• Billing Office Form

Developed by the Center for Infants and Children with Special Needs at Cincinnati Children’s Hospital Medical Center & The National Center of Medical Home Initiatives for Children with Special Needs.

Bridges to Excellence: Rewarding Quality Across the Healthcare System
...payments for care should be redesigned to encourage providers to make positive changes to their care processes. Ideally, this shift will begin with purchasers and insurers, and filter down through the delivery system to help encourage improvements at all levels. From the Institute of Medicine (IOM) report entitled " Crossing the Quality Chasm."

In response to this challenge, a group of employers, physicians, health plans and patients has come together to create Bridges to Excellence.

• Providing tools, information and support to consumers of health care services,
• Conducting research with respect to existing health care provider reimbursement models,
• Developing reimbursement models that encourage the recognition of health care providers who demonstrate that they have implemented comprehensive solutions in the management of patients and deliver safe, timely, effective, efficient, equitable and patient-centered care which is based on adherence to quality guidelines and outcomes achievement.

For more information on these tools and models click here.

From The Arc of the United States "Community for All" Tool Kit
This tool kit was developed at the request of volunteers, advocates, self-advocates, and professionals concerned that the remarkable progress made towards the inclusion of people with cognitive, intellectual and developmental disabilities (our constituents) into the fabric and mainstream of community life in America was at risk. In some places in the United States there are those who would not only continue to deny people currently in public and private institutions freedom and opportunity through continued institutionalization but who also want to expand the role of institutions in the lives of our constituents.

Tool Kit - PDF (15 mb) | Order Form | Web site

The Center for Children with Special Needs Medical Home Toolkit
This took kit can help primary care providers, health professionals and medical office staff work together with families of children with special needs. Below are links to resources or PDF files included in the toolkit that can be printed and copied for use in the medical home in the following categories.

• Emergency Plan
• Resources
• Family Support
• Health Education
• Care Organizing Tools
• Anticipatory Guidelines

Medical Home Improvement Toolkit Sections on Chronic Condition Management and Care Coordination
Common to each of the care coordination themes is the identification of needs and actions to address those needs. Care Coordination may be a new role for primary care practices yet many care coordination activities are not. Care coordination is essential to building a medical home; a medical home without a care coordinator is limited in its ability to expand its organizational capacity and fully serve CSHCN and their families.

Chronic Condition Management
This section of the toolkit on Chronic Condition Management (CCM) encompasses several issues relating to the extra layers of care and care continuity necessary for each child with special health care needs.

• Identification of Children in the Practice with Special Health Care Needs
• Care Continuity
• Continuity across Settings
• Cooperative Management Between Primary Care Provider and Specialist
• Supporting the Transition to Adult Health Care Services
• Family Support

Care Coordination, Community Outreach, Data Management, and Quality Improvement/Change
This section explains how care coordination is a core of a medical home. "It is essential to being able to respond to many of the needs that children and families experience on a daily basis." Six Care Coordination themes include:

1. Role Definition
2. Family Involvement
3. Child and Family Education
4. Assessment of Needs/Plans of Care
5. Resource Information and Referrals
6. Advocacy

Center for Medical Home Improvement
Crotched Mountain
1 Verney Drive
Greenfield, New Hampshire 03047
Phone: (603)547-3311 ext. 272 Fax: (603)547-3232
www.medicalhomeimprovement.org/mhik.htm

Enhancing Collaboration Between Primary and Subspecialty Care Providers for Children and Youth With Special Health Care Needs | Workbook
Antonelli, R., Stille, C., and Freeman, L. , Georgetown University Center for Child and Human Development, Washington, DC, 2005.

"An essential component of the Medical Home model is the ability to provide services that are coordinated. But who is responsible for coordinating care?
Without question, the family and patient are the principal coordinators of care. However, it is vital that all providers within the Medical Home model of care understand their interdependent roles and effectively serve the child and family. Indeed, the collaboration between primary and subspecialty providers is a critical aspect of coordinated care
within a Medical Home model."

Goals of This Guide
• Discuss the complementary roles of generalist and subspecialist physicians in providing coordinated and effective care for CYSHCN.
• Emphasize the centrality of family-professional partnerships.
• Describe various models for collaboration among generalist and subspecialist physicians and families.
  
  Ultimately, the value of this guide will be to serve as a framework for discussion about how primary and subspecialty care physicians can work collaboratively to enhance the quality of care that CYSHCN and their families receive. While it is essential to appreciate the structural and functional differences among various health care delivery systems, a core expectation for creating Medical Homes is that each system and community will embrace the critical components underlying collaboration outlined in this guide.
  
  Table of Contents
  
• Why Is Collaboration Between Primary and Subspecialty Care Providers Important
• What Is the Framework for a Collaborative Model of Care for CYSHCN?
• Implementation of Collaborative Care Between Primary and Subspecialty Care Providers
• Special Challenges and Opportunities
• Measures of Health Care Quality
• Resources and Tools to Enhance Collaboration in Caring for CYSHCN
• Very Useful Web sites

Tools for Enhancing Care Coordination Adobe PDF
The Physician's Guide to Caring for Children with Disabilities and Chronic Conditions, edited by Drs. Robert E. Nickel and Larry W. Desch, provides valuable tools and information on the complexities of providing comprehensive care coordination for children with special health care needs (CSHCN).

These tools include Coordination of Care Summaries, which should prove valuable in facilitating collaborative communication among the family, the primary care physician and the sub specialists:

• Situational Stressors and Family Risks Assessment
• Effect of Child's Disability on Family Members Interview
• Family and Physician Management Plan Summary for Children and Adolescents with Cerebral Palsy
• Family and Physician Management Plan Summary for Children and Adolescents with Meningomyelocele
• Family and Physician Management Plan Summary for Children and Adolescents with Cleft Lip and Palate
• Family and Physician Management Plan Summary for Children and Adolescents with Seizure Disorder
• Family and Physician Management Plan Summary for Children and Adolescents with Traumatic Brain Injury
• Family and Physician Management Plan Summary for Children and Adolescents with Down Syndrome
• Family and Physician Management Plan Summary for Children and Adolescents with Developmental Delay or Mental Retardation
• Medication Record
• Primary Care Family Assessment
• Craniofacial Disorders Psychosocial Screening Form
• Seizure Record

Last updated September 13, 2007