The Care Coordination Fundamentals curriculum consists of four (4) modules or sections that are structured to build on one another sequentially. All front-line staff working in a team-based healthcare environment will benefit from this course. This advanced version of the care coordination curriculum introduces staff to chronic, mental and behavioral conditions, (i.e. diabetes, hypertension, high cholesterol, asthma, depression, substance abuse etc.) and helps them understand these conditions and provides participants with coaching tools on how to teach patients to manage their health.

Participants will experience a highly interactive class environment tailored to adult learners. Our approach strengthens the participants’ critical thinking skills by engaging them in discussion, individual exercises and group activities. Participants complete the course prepared to assist their patients in navigating the healthcare system, and to be strong, productive members of healthcare teams providing coordinated and patient-centered care.

Basic care coordination

Module 1 –Orientation/Care Coordination Basic Skills Part 1

• Describe the role and responsibility of staff who provide care coordination
• Explain how care coordination is related to patient navigation
• List typical care coordination services
• Describe the qualities and skills needed by staff members providing care coordination

Module 2- Orientation/Care Coordination Basic Skills Part 2

• Define what a chronic disease is and how it relates to our healthcare system today
• Define coordinated care and patient centered care
• Describe the new models of healthcare such as Health Homes, Patient Centered Medical Home, ACOs where care coordination staff might work
• Describe what it means to work as part of a medical team and describe how staff providing care coordination fit with the rest of the medical team
• Explain what the Patient’s Bill of Rights is

Module 9- Basic Communication Skills

• Understand why care coordination staff need excellent communication skills
• List best practices for communicating with patients in person, by phone and email
• List best practices for communicating with an interdisciplinary team
• Discuss how body language and tone affect communication
• Describe what good customer service is
• Understand basic conflict management skills as needed to deliver excellent customer service

Module 17- Navigating the Insurance System/Helping the Uninsured (some topics)

• Increase basic understanding of Affordable Care Act (ACA)
• Increase basic understanding of Medicaid/Medicare/Managed Care
• Increase understanding of what it means to obtain referrals and authorizations
• Increase understanding of how to reduce barriers to care for uninsured and insured patients

Module 23 and 24- Professional Boundaries 1 & 2 (modules will be combined)

• Describe the role professional boundaries have in helping patients
• Describe ways to maintain healthy boundaries
• List risky behaviors that lead to boundary violations
• Understand what professional boundaries are needed when providing care coordination and when to ask for help from care management team
• Understand the relationship between personal boundaries and burn-out
• Identify the benefits of stress-management as a staff member providing care coordination services
• Identifying strategies for wellness and stress reduction
• Reflect on the care coordination role

Advanced care coordination

Module 3- Basics: Common Chronic Diseases/ Health and Wellness 1

• Review definitions of Health Homes and Patient Centered Medical Homes
• Understand the “clinical” role of staff providing care coordination
• Understand the basics of diabetes: most common diagnostic tests and treatments, specialists that patients with these conditions commonly need to see, and danger signs and symptoms
• List different ways that patients cope with having a chronic disease
• Know how to help patients talk to their doctors and prepare them for productive medical visits

Module 4- Basics: Common Chronic Diseases/ Health and Wellness 2

• Understand the basics of hypertension
• Understand the basics of high cholesterol
• Understand the basics of asthma
• Describe healthy behaviors and risk factors related to diet, exercise and smoking

Module 11- Basics of Mental Illness and Crisis Management 1

• Understand connection between mental health and chronic disease management
• Understand role of care coordination in helping patients with mental illness
• Understand characteristics of common mental illnesses such as depression
• Understanding of basic risk assessment for depression and suicidal ideation

Module 13- Basics of Mental Illness and Crisis Management 3

• Describe the role of front-line care coordination staff in dealing with a patient crisis
• Understand the difference between positive and negative coping strategies
• Understand the characteristics of substance abuse
• Understand the characteristics of domestic violence
• Understand the characteristics of loss and grieving