5.E) Referral & Specialty Care Coordination

High Value Care Coordination (HVCC) Toolkit External Link

Tools & Guides - February 13, 2018
American College of Physicians (ACP) -

High Value Care requires patient-centered care coordination between primary care and subspecialty/specialty practices. ACP's High Value Care Coordination Toolkit was developed under the direction of ACP’s Council of Subspecialty Societies, and includes checklists, outlines, and resources pertinent to High Value Care Coordination.

Referrals, Access and Continuity

Webinar  - 
Wednesday, November 15, 2017 - 7:30am to 8:30am

Join PCPCH program staff for this in-depth technical assistance webinar on implementing four of the most transformative measures in the PCPCH model.  PCPCH program staff will share best practices they have learned from visiting 5 STAR designated clinics across the state.  Featured measures include:

Closing the Referral Loop Tool Kit External Link

Tools & Guides - June 19, 2017

This is a tool kit to help clinicians address the interoperability of EHRs, to improve their workflows, and to close more referrals. The tool kit provides practical guidance on measures, how to create an improvement plan, sample care compacts, satisfaction surveys, and more.  

Scroll to the bottom of the page and click on "tool kit" then enter your information to download the document.

Beyond Developmental Screening: Children Identified At-Risk

Webinar  - 
Thursday, March 23, 2017 - 8:00am to 9:00am

The webinar is useful for patient-centered primary care homes, staff with CCO’s who are focused on the developmental screening metric, and Early Learning Hub staff focused on enhanced collaboration with primary care practices who are conducting developmental screening to ensure follow-up.

Pediatric Care Coordination Assessment External Link

Tools & Guides - September 13, 2016
Lucile Packard Foundation for Children's Health -

Identifying, accessing and coordinating services that benefit an individual child or youth with special health care needs is a difficult but necessary part of good quality health care. The best means of guiding and documenting these efforts is an individualized and comprehensive plan of care. This report, and its accompanying implementation guide, recommend core content of a comprehensive and integrated plan, and outline the steps necessary to achieve it.

Pediatric Medical Complexity Algorithm (PMCA) External Link

Tools & Guides - September 13, 2016
Seattle Children's -

The PMCA was developed by a team at Seattle Children's and validated by Center of Excellence on Quality of Care Measures for Children with Complex Needs (COE4CCN) efforts as a way to target and allocate care coordination resources.

There is both an excel file version and a SAS file version.

Referral Management External Link

Tools & Guides - June 23, 2015
Primary Care Team Guide -
This resource is a team guide for effectively managing referrals in a primary care practice setting. Unless well-coordinated, referrals can be frustrating or even dangerous. Referral management helps ensure prompt completion of services and efficient sharing of information.

Referral Tracking & Care Coordination

Webinar  - 
Wednesday, May 27, 2015 - 8:00am to 9:00am

Join us for an interactive webinar focusing on referral tracking and cooperation/relationship building between primary care clinics and specialists, social services, dental, and other community health partners.