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Our funding for updating this website ended in 2011, but the resources we developed are still helping clinical practices from around the world to transform the care they provide to better serve patients with chronic illness. Please visit our home page to learn more—or check out our more recent tools and resources at:


Tools & Resources

Following is an annotated table of contents for the tools and resources mentioned throughout the Care Coordination toolkit. Each was selected for its value in supporting practices in their efforts to coordinate care effectively.
1.  NCQA Care Coordination Process Measures
This table provides quality measurement items from relevant standards from the National Committee for Quality Assurance measurement set. [link]
2. Care Coordination Questions from Validated Instruments  
This table is an aggregation of patient survey items relevant to the key concepts for referral coordination excerpted from the major validated instruments currently used to monitor quality of care delivery. [link]
3. Referral Tracking Guide
This document on the American College of Physicians Practice Improvement and Innovation website lays out the goals and  mechanics of referral tracking. [link]
4. Referral Coordinator Job Description
This job description is a generic document generated from many job descriptions within various delivery systems that were posted on the Internet or supplied by organizations interviewed. It contains skills, tasks, and responsibilities that were  present across the many descriptions. It also reflects the focus on basic referral coordination tasks, rather than the more clinical tasks included in some care coordination positions and case management positions. [link]
5. Referral Coordinator Curriculum
For practice teams or delivery systems that wish to train existing staff members to fill referral coordinator functions, this curriculum outline provides a structure with training modules that mirror the elements of the Care Coordination Model. [link] 
6. Patient Referral Checklist
This document is designed to be given to patient prior to their specialist visit by the referral coordinator.  The document provides information to prepare patients for their upcoming appointments and prompts them to be active participants in the referral process. [link]
7. The Care Transitions Program®
This program, under the direction of Dr. Eric Coleman, has done fundamental research in improving the care and outcome of patients discharged from hospital, and is now being disseminated. The Care Transitions Program® website includes many tools for patients and families to ensure active and informed management activities to assure safety through care transitions. [link]
8. Patient Activation Assessment Form
This Care Transitions Program® tool, for use with patients in transition, measures progression of activation in transition-
related self-care skills, assessing confidence in four critical areas of patient activity. It should not be converted into a provider-oriented checklist. The document is free to all. Please see the website for terms of use and attribution. [link]
9. The Post-Hospital Follow-Up Visit: A Physician Checklist to Reduce Readmissions
Coleman, EA, The Post-Hospital Follow-Up Visit: A Physician Checklist to Reduce Readmissions, The California HealthCare Foundation, October 2010. [link]
10. Coordinating Care in the Medical Neighborhood:  Critical Components and Available Mechanisms
Taylor EF, Lake T, Nysenbaum J, Peterson G, Meyers D. Coordinating care in the medical neighborhood: critical components and available mechanisms. White Paper (Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I TO2). AHRQ Publication No. 11-0064. Rockville, MD: Agency for Healthcare Research and Quality. June 2011. [link]
11. Colorado Patient-Centered Primary Care Collaborative: Colorado Primary Care–Specialty Care Compact
This compact contains definitions, outlines types of care management transitions, provides points for mutual agreement, and provides expectations for primary and specialty care in terms of access, transitions, collaborative management, and patient communication. [link]
12. Federal Expert Work Group on Pediatric Subspecialty Capacity. Promising Approaches for Strengthening the Interface between Primary and Specialty Pediatric Care.
Maternal and Child Health Policy Research Center, American Academy of Pediatrics and the Maternal and Child Health Bureau Department of Health and Human Services. March 2006.  
This guide outlines promising referral practices, consultation approaches, and collaborative management approaches between pediatric subspecialties and primary care practices. [link]
13. Berta W, Barnsley J, Bloom J, et al. Enhancing continuity of information: essential components of a referral document. Can Fam Physician. Oct 2008;54(10):1432-1433, 1433 e1431-1436.
This journal article provides detailed information on required domains and data fields to include in referral documents and  consultation reports.  [link]
14. Berta W, Barnsley J, Bloom J, et al. Enhancing continuity of information: essential components of consultation reports. Can Fam Physician. Jun 2009;55(6):624-625 e621-625.
This journal article provides detailed information on required domains and data fields to include in referral documents and  consultation reports.  [link]
15. Reichman M. Optimizing referrals & consults with a standardized process. Fam Pract Manag. Nov-Dec 2007;14(10):38-42.
This e-journal article provides guidance about standard information and processes that lead to optimal communication  between primary care practices and consulting physicians to ensure that referrals and consultations run smoothly
for everyone involved. A sample referral and consultation form is included.  [link]
16. Bridging the Care Gap: Using Web Technology for Patient Referrals
California HealthCare Foundation; September 2008.
This 2008 report examines eight Web-based referral systems, including five that are commercially available. The report explores common functions of the new software applications, outlines considerations for those interested in adopting such  systems, and highlights providers' successes and challenges in using them. Four case studies are also included. [link]
17. O'Malley AS, Grossman JM, Cohen GR, Kemper NM, Pham HH. Are electronic medical records helpful for care coordination? Experiences of physician practices. J Gen Intern Med. Mar 2010;25(3):177-185.
This journal article describes the actual role that EMRs are playing in efforts to coordinate care, and contrasts it with the  potential that linked EMRs with standardized data could have.  [link]