Care Coordination Roles Planning Matrix Template How to Use: See in the CCC Toolkit. Care Coordination Roles Planning Matrix Care Coordination Role role> role> director director staff LPN or manager needed… staff manager professional P = primary responsibility as case staff/scheduler resource resource Nurse coordination coordination staff/receptionist S = secondary or support responsibility assistant health improvement worker manager plan educator care care program coordinator columns manager Care Coordination Activity registration Medical Mental Health Nutritionist Health Quality Health Add CCC Care Back-office Registered Community Community Clinic Social Front-desk Provider—MD Provider—NP ED ED Pharmacist <other <other Provider—PA 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)
Care Coordination Roles Planning Matrix Template How to Use: See Care Coordination Roles Planning Matrix in the CCC Toolkit. Care Coordination Role P = primary responsibility S = secondary or support responsibility Care Coordination Activity CCC program manager Care coordinator Social worker Health plan case manager Front-desk staff/receptionist Back-office staff/scheduler Medical assistant or LPN Provider—MD Provider—PA Provider—NP Registered Nurse Mental health professional Nutritionist Health educator Community resource director Community resource staff Quality improvement director ED registration staff ED manager Clinic manager Health Pharmacist <other care coordination role> <other care coordination role> Add columns as needed… 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)