Care Coordination

Upcoming Events


Previous Sessions

Materials from previous learning sessions are found below.

February 9 Care Coordination Presentation 1

February 9 Care Coordination Presentation 2

February 9 Care Coordination Presentation 3

February 9 Care Coordination Presentation 4

February 9 Care Coordination Presentation 5

May 25 Motivational Interviewing

Care Coordination Network October 3-4, 2017 (3 Parts)

Part 1, Part 2, Part 3

Documents Referenced in Rachel Wallis’ Care Coordination Training

AAFP Care Plan
Activity Example 4 Cut Method Worksheet
Ampersand – City Life – Member focused elective – observation and evaluation
Appointment Management Workflow
Care Management Visit
Care Plan Implementation Guide
Care Team Roles and Responsibilities Activity
Detail Process Follow Up Appointments
Empanelment Process
Example of Traditional Practice Versus Team
Huddle Worksheet
Implementation Guide Enhanced Access
Model Overview
Nuka Module Advanced Access Clean 3-11
Open Access at Primary Care Partners
Panel Management
Panel Supply vs Demand
Risk Stratification Tip Sheet
Risk Stratification Evaluation Worksheet
Risk Stratification Workshop Day 2 Comments Review
Risk Stratified Care Management Workshop Idaho Day 1 Comment Review
Risk Stratification Discussion Questions
Scheduling Guidelines
Tasks for TCM
Tool Access Communication Policy Outline
Transitions of Care Info Protocol Activity
Workflow-Pre Visit Planning – Clopton Clinic


Care Coordination Directory


Chronic Care Management: New Connected Care Videos

The CMS Connected Care campaign has new videos:

  • Physician Testimonial: A rural physician shares her experience offering Chronic Care Management (CCM) services (2 minutes)
  • Connecting the Dots (English and Spanish): This animated video provides CCM services information for Medicare beneficiaries living with multiple chronic conditions (30 seconds)

You can also download posters and postcards about CCM from the Connected Care website or request printed copies at no cost from the CMS Product Ordering website:.

  • Postcard for Health Care Professionals (Pub # 909444): An overview of CCM, the four billing codes for payment, and how to learn more about implementation
  • Postcard for Consumers (English and Spanish, Pub #909443): Helps you explain CCM and its benefits
  • Poster (English and Spanish, Pub #909445): Display in office or waiting room to get your patient’s attention and help start the conversation

For More Information:


Pfizer RxPathways Resource

Pfizer RxPathways connects eligible patients to assistance programs that offer insurance support, co-pay assistance, and medicines for free or at a savings.  For color flyer, click here.  To go to website, click here.

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