TransforMED’s Care Coordination Workbook

TransforMED’s Care Coordination Workbook

The ongoing relationship between the patient and the provider is a cornerstone of primary care.
Item # 8268

ISBN: 9781568293837

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The ongoing relationship between the patient and the provider is a cornerstone of primary care. The healthcare system oftentimes can be a confusing tangle of complicated interactions for patients.

The PCMH model encourages practices to guide patients beyond the practice setting. This can be done through cooperative alliances with essential healthcare services that offer a complete range of needs for a given patient population.

Care coordination involves developing structured relationships with individuals and facilities outside of the primary care setting that are necessary to provide comprehensive care. A need for care beyond the scope of the primary care office occurs frequently, and it is important to include this care in the overall management of the patient.

Care coordination expands the definition of team to include all providers, locations and resources necessary to meet the patient’s healthcare needs. This extended care team can include specialists, hospital facilities, home health facilities, long-term care facilities, durable medical equipment vendors, public health entities, pharmacists, social workers, psychologists, physical therapists and any other healthcare entity that affects the patient’s healthcare.

Effective care coordination provides for an understanding of each team member’s role and responsibility at the time of the patient interaction and a clearly defined information flow between team members. Each team member has accurate current information for every patient at each encounter.

Topics covered in this book include:

  • Obstacles to effective care coordination
  • The care coordination process
  • Coordination with hospitals, emergency rooms, and urgent care facilities
  • Coordination of care provided by specialist physicians
  • Planning for effective care coordination
  • Implementation
  • Care coordinator role
  • And more than 20 templates are included for your immediate use

2010, 82 pp., ISBN 978-1-56829-383-7

PCMH Care Coordination Workbook

Table of Contents


  • Explanation of the TransforMED Model
  • Description of Individual Modules
  • Patient-centered Care
  • Access to Care and Information
  • Practice-based Services
  • Care Management
  • Care Coordination
  • Practice-based Team Care
  • Quality and Safety
  • Health Information Technology
  • Practice Management
  • Interconnectivity of the Modules
  • Transformational Principles
  • Leadership
  • Teamwork
  • Communication
  • Change Management
  • Relationship-building
  • The Transformational Journey


  • Care Coordination
  • Trends of Complexity in Healthcare Needs
  • Obstacles to Effective Care Coordination
  • Patient Obstacles
  • Physician/Practice Obstacles
  • Facility Obstacles
  • Payer Obstacles
  • Community Obstacles
  • Summary

Chapter 3 - WORKBOOK

  • Care Coordination Process
  • Patient Population
  • Panel size
  • Age and gender demographics
  • Chronic disease demographics
  • High-risk–high-acuity demographics
  • Significant risk factors
  • Coordination with Hospitals, Emergency Rooms, and Urgent Care FacilitiesFacilities used by your patients
  • What and how information is shared
  • Office workflow
  • Coordination of Care Provided by Specialist Physicians
  • Identify frequently used specialist physicians
  • What and how information is shared
  • Office workflow
  • Planning for Effective Care Coordination
  • Engaging a Team
  • Reaching Consensus
  • Defining Appropriate Information
  • Determining an Efficient Mechanism for Sharing Information
  • Evaluating Office Workflow
  • Implementation
  • Communicating and Negotiating Needs
  • Developing and Facilitating an Agreement
  • Follow-up
  • Additional Opportunities for Coordination of Information
  • Care Coordinator Role

Appendix A - TEMPLATES

  • Appendix A.1 How Information is Provided from Primary Care Practice to Outside Facilities on a Regular Basis
  • Appendix A.2 Information from Primary Care Practice Sent to Outside Facilities on a Regular Basis
  • Appendix A.3 How Information is Provided from the Outside Facility to Primary Care Practice
  • Appendix A.4 Information Provided to Primary Care Practice from Outside Facilities on a Regular Basis
  • Appendix A.5 Time Lapse from Event to Information Available at Primary Care Practice
  • Appendix A.6 List Specialist Physicians, Contact Information, and Contact Method
  • Appendix A.7 Referral/Consult Form
  • Appendix A.8 Outgoing Referrals – Simple Form
  • Appendix A.9 Current Method of Communication from PCP to Specialist Physician
  • Appendix A.10 Current Method of Communication from Specialist Physician to PCP
  • Appendix A.11 Information Currently Provided to PCP Following a Consult
  • Appendix A.12 Time Lapse for Information Availability to PCP
  • Appendix A.13 Current Mechanisms from Primary Care Practice to External Providers/Facilities
  • Appendix A.14 Current Mechanisms from External Providers/Facilities to Primary Care Practice
  • Appendix A.15 Hospital Follow-up Workflow
  • Appendix A.16 Hospital Follow-up Protocols
  • Appendix A.17 Hospital — Primary Care Practice Sample Agreement
  • Appendix A.18 Specialist — Primary Care Practice Sample Agreement
  • Appendix A.19 Sample Care Coordinator Job Description

Appendix B - DEFINITIONS - 79


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