Patient Centered Medical Home

Coordinated Care

Resources

There are tools and resources available in the Coordinated Care reference library that will provide more information about these principles.

Type	Title	Abstract	PDF	HTML
Paper	Enhancing the Primary Care Team to Provide Redesigned Care: The Roles of Practice Facilitators and Care Managers	Efforts to redesign primary care require multiple supports. Two potential members of the primary care team—practice facilitator and care manager—can play important but distinct roles in redesigning and improving care delivery.	(PDF-84KB) PDF Help	(Coming soon)
Brief	Ensuring that Patient Centered Medical Homes Effectively Serve Patients with Complex Needs	The PCMH model currently offers or coordinates many of the services required for patients with complex needs. This decisionmaker brief offers programmatic and policy changes that can help practices, especially smaller ones, better deliver services to all patients, including those with the most complex health needs.	(PDF-175.75KB) PDF Help	HTML
White Paper	Coordinating Care for Adults with Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions	Patients who have complex health needs typically require both medical and social services and support from a wide variety of providers and caregivers. This paper discusses strategies that are needed to help primary care practices perform as effective medical homes to coordinate such services for patients with complex care needs.	(PDF-91.18KB) PDF Help	HTML
White Paper	Integrating Mental Health and Substance Use Treatment in the Patient-Centered Medical Home	The majority of PCMH demonstrations have not explicitly addressed the integration of mental health services into primary care. This paper examines successful approaches to delivering mental health treatment in primary care and PCMH settings.	(PDF-181.16KB) PDF Help	HTML
White Paper	Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms	“Neighbors” in the medical neighborhood include the medical home, specialists, hospitals, health plans, and other stakeholders. This paper describes how these neighbors could work together better, thus allowing the medical home to reach its full potential to improve patient outcomes.	(PDF-663.28KB) PDF Help	HTML
White Paper	The Roles of Patient-Centered Medical Homes And Accountable Care Organizations in Coordinating Patient Care	PCMH and ACO models of care delivery can work in tandem to increase the effectiveness of care coordination. Medical homes can directly coordinate services, while ACOs can facilitate and incentivize collaboration across various providers and organizations	(PDF-340.27KB) PDF Help	HTML
Report	Care Coordination Accountability Measures for Primary Care Practice	This resource was developed in response to the need for measures for assessing or recognizing care coordination as it is carried out by primary care practices. The report lists care coordination measures selected systematically from AHRQ’s Care Coordination Measures Atlas (see above) that are well suited for use by health plans and insurers to assess the quality of care coordination in primary care practices and by primary care practices themselves to assess their own performance.	(PDF-300.88KB) PDF Help	(Coming soon)
Report	Care Coordination Measures Atlas	This resource lists existing measures of care coordination, with a focus on ambulatory care, and presents a framework for understanding care coordination measurement. The Atlas is useful for evaluators of projects aimed at improving care coordination and for quality improvement practitioners and researchers studying care coordination.	(PDF-2.2MB) PDF Help	HTML
Report	Report Prospects for Care Coordination Measurement Using Electronic Data Sources	This report presents an assessment of the potential for measuring care coordination processes using data from electronic data sources, in particular from existing and emerging health information technology systems such as electronic health records, health information exchanges, and all-payer claims databases.	(PDF-300.88KB) PDF Help	(Coming soon)