Health Care Homes
Learning Collaborative
Fundamentals of Care Coordination - Resources
Quadruple Aim
Treat High-need, High-cost Patients
Triple Aim
Assessing Your Needs
- Community Health Assessment (MDH)
- Emotional Intelligence in the Nursing Profession (ASRN)
- Organized, Evidence-Based Care: Planning Care for Individual Patients and Whole Populations (Qualis Health) (PDF)
- Six Seconds Emotional Intelligence Assessment - Measure and improve emotional intelligence (SEI)
- STAR Interviewing Model for Behavioral Interview Questions (careerprofiles.info)
Quality Improvement and the Care Coordinator
- Improving Primary Care (AHRQ)
- Measuring Care Coordination in Medical Homes (Commonwealth Fund)
- Model for Improvement (IHI)
Recognizing and Preventing Care Coordinator Burnout
TeleHealth
What is a Care Coordinator?
Where to Find a Care Coordinator
Managing Care Transitions
- A Resource Guide: Information, Strategies, and Tools for Managing Care Transitions (Care Providers) (PDF)
- Managing Transitions with a Pediatric Population (Got Transition)
Patient Centered Care
- Advancing the Practice of Patient and Family - Centered Care in Primary Care and Other Ambulatory Settings, How to Get Started (IPFCC) (PDF)
- Advancing the Practice and Understanding of Patient- and Family-Centered Care (IPFCC)
- A Collection of Resources (MDH)
- Overview of Care That is Person & Family Centered (PCPCC)
- Implementation Guide, Patient-Centered Interactions (SNFI) (PDF)
- Eliciting the Patient’s Perspective (SNFI) (PDF)
- The Patient-Centered Medical Home from the Patient’s Perspective (SNFI) (PDF)
Patient Engagement and Activation
- A Collection of Tools and Strategies to Increase Patient Health Literacy (AHRQ)
- Guide to Implementing the Health Literacy Universal Precautions Toolkit (AHRQ)
- Guide to Strengthening Patient Engagement in Their Care (AHRQ)
- Overview of Health Literacy with Links to Resources (CDC)
Team Based Workflows
- Functions of the Medical Home: Comprehensive, Team-Based Approach to Care (AHRQ)
- Health Care System Redesign (AHRQ)
- Improving the Care Team’s Performance and Enhancing Patient Safety (AHRQ)
- Information and Resources for Building and Sustaining Effective Care Teams (AHRQ)
- Research - Examining the Perspective of Care Coordinators in Patient-Centered Medical Homes on Their Role (NCBI)
Behavioral Health, Tools and Strategies for Care Coordinators
- National Alliance on Mental Illness Minnesota - Locate Services and Support for Patients (NAMI)
- Mental Health Minnesota - Information, Fact sheets, and Worksheets to Assist Individuals in Developing a Healthy Lifestyle as a Support for Mental Health (Mental Health MN)
- Mental Health by the Numbers (NAMI)
- Depression in Older Adults (NIA NIH)
- Authoritative Information about Mental Disorders (NIMH)
Community Partnerships
- Information on and Insight Into How to Build Community-Healthcare Partnerships (AHA) (PDF)
- Using Community Partnerships to Integrate Health and Social Services for High-Need, High-Cost Patients (Commonwealth Fund)
- Making Community Partnerships Work: A Toolkit / March of Dimes (AAPCHO) (PDF)
Cultural Competence
- Cultural Responsiveness (Cultural Care Connection)
- Culture Care Connection - Information, Tools, and Resources Supporting the Delivery of Culturally Competent Care (Stratis)
- Georgetown University: Cultural and Linguistic Competence (NCCC)
- The SHARE Approach—Taking Steps Toward Cultural Competence: A Fact Sheet (AHRQ)
- Health Resources and Services Administration (HRSA)
- Positive Youth Development Resources (OASH)
- National Resource Center for Patient/Family-Centered Medical Home, a national technical assistance center (AAP)
- Practical Strategies for Culturally Competent Evaluation (CDC) (PDF)
Literacy Learning
Motivational Interviewing and Coaching
- Examples of Motivational Interviewing Techniques to Support Behavior Change in Patients With Multiple Chronic Conditions (Lake Superior QIN)
- Training Video (MINT)
Shared Decision Making and SMART Goals
- Description of SMART Goals, Including Tools and Resources for Writing and Using Them (MDH)
- The SHARE Approach - An Overview of Shared Decision-making, Focusing on Five “Essential” Steps (AHRQ)
- Shared Care Planning and Coordination for Long-Term and Post-Acute Care (CAST) (PDF)
- Enhancing Patient Engagement through Shared Decision-Making (NQF)
- Minnesota Shared Decision-Making Collaborative - Multi-Stakeholder Community Learning Collaborative - Shared Decision-Making in Clinical Practice throughout Minnesota (MSDMC)
- A Guide For S.M.A.R.T Goal Setting (ACE)
- The Essential Guide to Writing SMART Goals (Smartsheet)
- 5 Steps to Setting Smart Goals (Smart-goals-guide)
- Overview of Objectives, How to Write SMART Objectives, a SMART Objectives Checklist, and Examples of SMART objectives (CDC) (PDF)
Social Determinants of Health
- PRAPARE Implementation and Action Toolkit - A Resource for Gathering, Assessing, and Responding to Data on the Social Determinants of Health (NACHC)
- Overview of SDOH and how some healthcare organizations are addressing them (NEJM)
Trauma Informed Care
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Last Updated: 10/22/2024