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Improving Care Coordination Across the Medical Neighborhood

A Patient-Centered, Team-Based Approach

To effectively manage chronic conditions among patients in vulnerable communities, providers must utilize and optimize care teams that support patients through the cascade of care. Yet successful care teams collaborate not only within the health center, but also within patient communities. By incorporating community partners and stakeholders as part of the medical neighborhood, care teams can coordinate care that meets a patient’s needs in and outside of the provider’s office. The National Nurse-Led Care Consortium (NNCC) and the Washington Association for Community Health are convening a learning collaborative of health centers interested in enhancing care coordination efforts to improve clinical outcomes for patients. The learning collaborative is designed so that participants can bring lessons learned back to their health centers and train additional staff in care coordination and team based care optimization competencies. It is recommended that health centers bring a team including diverse roles to learn and plan together. A recommended iteration of a participating team includes 4 health center staff, including: 1) clinical director or provider; 2) medical assistant; 3) nursing staff member or care coordinator; and 4) clinical administrator or front desk supervisor.

MODULE 1: Introduction to Care Team Formation
MODULE 2: Framing Continuous Quality Improvement
MODULE 3: Improving Care Coordination across the Medical Neighborhood
1. Communication
2. Role & Role Optimization
3. Care Coordination
Case Studies
​MODULE 4: Follow Up and Peer Learning
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