Community Care Coordination and Chronic Care Management

Hospital Best Practices and Recommended Strategies

The tools and resources below help leaders with community health planning and guide hospitals with developing and implementing Patient-Center Medical Home (PCMH) and other community care coordination models, as well as chronic care management services.

Explore the findings from the 2020 Rural Behavioral Health Care Coordination Summit. The report offers tips on how to maximize available resources and new technology to improve efficiency in care management and transitions of care. It identifies some of the greatest barriers to care coordination and focuses on four areas of opportunity for addressing them. This summit built upon the findings of the 2019 Rural Care Coordination and Population Health Management Summit which includes a short video featuring panelists from the Summit, the webinar playback of the guide and report, and the Rural Hospital Guide to Improving Care Management.

Patient-Center Medical Home (PCMH)

Community Care Coordination Models

  • Develop an effective care coordination program using the Care Coordination Canvas Guide developed by The Center and RHI. 
    • The Canvas Tool incorporates the survey findings into a framework to develop effective care coordination programs. The tool is also useful for discovering implementation gaps and making improvements.
    • The Canvas Guide helps individuals use the canvas tool to develop and execute effective programs without an outside expert.
    • The Case Studies illustrate how communities are using the Care Coordination Canvas. They describe different care coordination approaches identified by the survey.
  • Actively plan for the sustainability of your already established care coordination program using the Sustainable Community Care Coordination Guide developed by The Center. This guide is meant to be used with the following tools:
    • Strategic and Marketing Thinking Canvas (Appendix A of the Guide): This first step will outline the things to consider throughout this process, along with a facilitation guide to help you lead this process with your stakeholders.
    • Sustainable Community Care Coordination Workbook (Separate document): Use this tool to record your work as you move through the guide.
    • Potential Partners Worksheet (Appendix B of the Guide): Use this tool to identify stakeholders both inside and outside of your organization.
  • Use Rural Health Value’s care management tools to initiate the integration and coordination patient-centered care to improve clinical outcomes
  • Implement the Care Coordinator Model (CCM) to help individuals with complex health conditions to navigate the health care system. CCM assists patients and families in addressing barriers to access such as language, culture, communication, transportation and helps patients and families transition between healthcare providers and healthcare settings.
  • Use the Rural Care Coordination Toolkit to develop and implement a care coordination program.
  • Use CMS’s Care Coordination Toolkit for ACOs to coordinate and manage care for Medicare’s diverse beneficiary populations.
  • Use the Community Health Workers (CHW) Toolkit to develop and implement a CHW program. CHW are non-medical health workers that help improve patient outcomes by assisting patients with learn about their disease and obtain screening and treatments.
  • Refer to Kentucky Homeplace for ways to use Community Health Workers to assist patients and families identify and find solutions to their health care needs. Kentucky Homeplace includes health educators.
  • Consider using a health navigator (HN) to assist patients through treatment and care and guide patients across healthcare settings

Chronic Care Management

Community Care Coordination Planning

  • Review IHI’s Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs white paper for suggested methods and opportunities to better coordinate care and key metrics for determining outcomes
  • Develop transition of care committee to include hospitals, physicians, emergency medical service (EMS) and other local agencies such as Home Health and Area Agency on Aging, as well as non-traditional health champions such as schools and churches
  • Develop and coordinate local providers to include home health, nursing home, hospice, emergency medical services (EMS), pharmacy, clinic, wellness center and Public Health Department
  • Host community provider quarterly meetings to initiate community health planning. These community health planning meetings benefit hospitals by establishing a venue for communication and sharing of community health resources across organizations.
  • Discuss and strategize how to meet community needs and determine the type of support needed
  • Use the Flex Monitoring Team’s State-level Quality, Financial and Community Engagement Data to support planning
  • Use the Network Care Coordination Workshop tools and trainings to initiate the development of a network care coordination service.

SRHT Project Success Story

This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UB1RH24206, Information Services to Rural Hospital Flexibility Program Grantees, $1,009,121 (0% financed with nongovernmental sources). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.