Medical Home - Practice-Based Care Coordination Workbook

This workbook includes the tools and supports needed for a primary care practice to develop their capacity to offer a pediatric care coordination service; particularly for children with special health care needs. The health care team, determined to develop such an explicit service, makes an assessment of current care coordination practice and frames their improvement efforts to achieve proactive comprehensive practice-based care coordination. Tools included in this resource are: a definition of care coordination in the medical home, a care coordination position description, a framework for care coordination services including structures and processes, strategies for the protection of devoted staff time, and a logical sequence of care coordination improvement ideas offered in the context of the Model for Improvement (Langley, 1996). Each tool can be used as is or it can be customized in a manner which best fits your practice environment and the strategic plans your organization holds for medical home improvement activities.


The material in these guides and tools was developed from the experiences of Regional Extension Center staff in the performance of technical support and EHR implementation assistance to primary care providers. The information contained in this guide is not intended to serve as legal advice nor should it substitute for legal counsel. The guide is not exhaustive, and readers are encouraged to seek additional detailed technical guidance to supplement the information contained herein.

Reference in this web site to any specific resources, tools, products, process, service, manufacturer, or company does not constitute its endorsement or recommendation by the U.S. Government or the U.S. Department of Health and Human Services.

Practice Role
Care Coordinators
Health Care Mgmt - Practice Mgrs Admin
Providers (MDs, DOs, NPs, PAs, RNs, LPNs)
PSR, Schedulers, Front Desk, Med Secretaries
Providers & Professionals
Setting/Practice Type
FQHC or Community Health Center
Large Practice 11 or more
Small Practice 1 - 10
Specialty Practice
Resource Topics
Patient and Family Engagement
EHR Steps
Step 5: Achieve Meaningful Use

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