Care Coordination Roles Planning Matrix TemplateHow to Use: See Care Coordination Roles Planning Matrix in the CCC Toolkit.

Care Coordination Role

P = primary responsibilityS = secondary or support responsibility

Care Coordination Activity CCC

prog

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man

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Care

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Soci

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Identify eligible patients

Develop patient recruitment strategy

Develop CCC brochure and/or videos

Recruit patients to program

Schedule initial face-to-face CC visit

Schedule follow-up face-to-face CC visits

Prepare CCC plan

Prepare patient care plan (for Pt)

Prepare patient action plan (with Pt)

Conduct medication reconciliation

Develop referral tracking/follow-up process

Schedule patient referrals

Track/follow-up on patient referrals

Prepare and review Pt health diary

Develop condition-specific education material

Provide condition-specific education (with Pt)

Section 2.5.1 Plan—Care Coordination Roles Planning Matrix Template - 1

Care Coordination Role

P = primary responsibilityS = secondary or support responsibility

Care Coordination Activity CCC

prog

ram

man

ager

Care

coo

rdin

ator

Soci

al w

orke

r

Heal

th p

lan

case

man

ager

Fron

t-de

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ce st

aff/s

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Med

ical

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Prov

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—M

D

Prov

ider

—PA

Prov

ider

—N

P

Regi

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urse

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Com

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Conduct health risk assessment(s)

Conduct environmental risk assessment(s)

Complete Pt care coordination variance log

Provide mental health crisis intervention

Monitor vital signs and report out-of-range

Develop wellness services plan

Develop patient self-management tools

Conduct self-management (with Pt)

Develop supportive communications tools

Develop shared-decision-making tools

Conduct shared-decision-making (with Pt)

Develop remote monitoring tools & process

Develop discharge CC checklist

Use discharge CC checklist

Develop/manage provider resource directory

Develop/manage community resource directory

Develop patient communication plan

Conduct pharmacist outreach

Conduct community outreach

Section 2.5.1 Plan—Care Coordination Roles Planning Matrix Template - 2

Care Coordination Role

P = primary responsibilityS = secondary or support responsibility

Care Coordination Activity CCC

prog

ram

man

ager

Care

coo

rdin

ator

Soci

al w

orke

r

Heal

th p

lan

case

man

ager

Fron

t-de

sk st

aff/r

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st

Back

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ce st

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ched

uler

Med

ical

ass

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t or L

PN

Prov

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—M

D

Prov

ider

—PA

Prov

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—N

P

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Com

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<other care coordination activity>

<other care coordination activity>

<other care coordination activity>

<other care coordination activity>Add rows as needed . . .

Section 2.5.1 Plan—Care Coordination Roles Planning Matrix Template - 3

Copyright © 2015 Stratis Health and KHA REACH. Updated 04/22/2015

Section 2.5.1 Plan—Care Coordination Roles Planning Matrix Template - 4