Care Coordination Tools and Resources
See below for tools and resources related to Care Coordination.
Community Coalition Participation Agreement
The most effective way to impact health care is to align efforts with those who have common goals. If you are partnering with us to improve health care outcomes, please sign the participation agreement: Community Coalition Participation Agreement.
Data Sharing Agreement
The overall purpose of sharing the data specified in this agreement is to allow community providers to view admission and readmission data to identify patterns and construct patient population profiles for potentially avoidable readmissions. The data-sharing agreement must be signed and can be accessed here: Data Sharing Agreement.
Do you have a story where a community coalition made a positive impact? Share it here!
How to Refer – Reference Partner Cards
Access Cards
Blood Pressure Measurement
See Resource
COPD Booklet
A practical guide to living with Chronic Obstructive Pulmonary Disease
See Booklet
Transitions of Care Toolkit
See Tool
Reduce the Risk of Hospital Readmission Flyer
See Tool
COPD Zone Tool
See Tool
Skilled Nursing Facility Rehospitalization Risk Assessment
See Tool
Heart Disease Zone Tool
See Tool
Living with Heart Failure Booklet
A Guide to Keeping a Strong and Steady Beat
See Booklet
Resident Information Booklet
Go to the hospital or stay here?
See Booklet
Skilled Nursing Facility (SNF) Resident Pre-Admission Checklist
See Tool
SNF Transfer Checklist
See Tool
Northwest Montana Care Transitions Coalition Referral Checklist – Montana
Developed by the Northwest Montana Care Transitions Coalition, this referral coversheet includes the phone and fax numbers for skilling nursing, long-term care and assisted living facilities in the Kalispell area along with a checklist of what should be transferred. Coalition members can submit updates to this referral checklist to Katie/via the contact us form.
Access tool here
West Oahu Provider Capabilities Poster – Hawaii
Developed by the West Oahu Community Partners Coalition. This poster shows what services each partner in the coalition offers, helping health care providers and patients identify what can be done with non-emergency health care providers. Coalition members can submit updates on the services for the next capabilities poster to Katie/via the contact us form.
Access tool here
Windward Provider Capabilities Poster – Hawaii
Developed by the Windward Community Partners Coalition. This poster shows what services each partner in the coalition offers, helping health care providers and patients identify what can be done with non-emergency health care providers. Coalition members can submit updates on the services for the next capabilities poster to Katie/via the contact us form.
Access tool here
West Oahu Discharge/Transfer Checklist
This tool can help ensure the right information is being transferred to the next care setting with every patient. Developed by the West Oahu Community Partners Coalition.
Access Tool Here
Community Partner Cards
Emergency Preparedness Guide
Use this guide to start and/or evaluate your emergency planning. The guide contains information to help identify key emergency roles and responsibilities along with planning for safe building evacuations, effective emergency communications, strategies for resuming normal functions and developing a definition of essential personnel, mission-critical functions, staff release-time policies and internal emergency communications procedures.
Access tool here
Emergency Preparedness Plan Template
Use this template to help with your emergency planning.
Access tool here
Emergency Procedures Flipchart
You can customize this tool to help with your emergency preparedness.
Access tool here
Emergency Preparedness Plan: After-Action Template
This tool can be used to evaluate the effectiveness and efficiency of an emergency preparedness plan.
Access tool here
Journey to Improved Kidney Care
An educational presentation by Dr. Jared Sugihara and Anthone Jeon, DNP, from Malama Kidney Center. Dr. Sugihara and Anthone discuss the prevalence of chronic kidney disease in Hawaii, and how Malama Kidney Center works with their patients to improve outcomes.
Watch the recording | See the slide deck
Mountain-Pacific Quality Health Montana Coalition Summit
Coalition members, health care workers, family members, care givers and more were invited to attend the September 21, 2021 summit. Community feedback and local perspectives from community and coalition members were shared during the townhall discussion.
Watch the recording | See the key takeaways
Mountain-Pacific Quality Health Wyoming Coalition Summit
Coalition members, health care workers, family members, care givers and more were invited to attend the September 9, 2021 summit. Community feedback and local perspectives from community and coalition members were shared during the townhall discussion.
Watch the September 9, 2021 recording | See the slide deck
Beneficiary and Family-Centered Care Quality Improvement Organization
Kepro is the Beneficiary-and Family-Centered Care-Quality Improvement Organization (BFCC-QIO) for 29 states, offering free services to people with Medicare (and their families) that include quality of care complaints, hospital discharge and skilled service termination appeals and immediate advocacy
This webinar offers a basic overview of these services and is ideal for health care providers and advocacy organizations.
Watch the November 2020 recording | See the slide deck
Data Comes in All Sizes – Webinar Series
Data comes in all sizes and Quality Assurance & Performance Improvement (QAPI) is applicable in many settings. Recorded for community coalitions, this webinar series focuses on the elements of QAPI.
- October 14, 2020 – Session 1: Watch the recording | See the slide deck
- October 28, 2020 – Session 2: Watch the recording | See the slide deck
- November 3, 2020 – Session 3: Watch the recording | See the slide deck
- November 18, 2020 – Session 4: Watch the recording | See the slide deck
- December 2, 2020 – Session 5: Watch the recording | See the slide deck
- December 9, 2020 – Session 6: Watch the recording | See the slide deck
Regional Community Coalition Quarterly Meetings
Each quarter regional community coalitions and coalition leads meet for quarterly regional community coalition meetings. During these meetings, attendees have the opportunity to learn best practices and share tips and tricks for creating a successful coalition.
- July 29, 2020 – Coalition Members: Watch the recording | See the slide deck
- October 27, 2020 – Coalition Members: Watch the recording | See the slide deck
- January 26, 2021 – Coalition Members: Watch the recording | See the slide deck
- April 27, 2021 – Coalition Members: Watch the recording | See the slide deck
- July 27, 2021 – Coalition Members: Watch the recording | See the slide deck
- January 25, 2022 – Coalition Members: Watch the recording | See the slide deck
- April 26, 2022 – Coalition Members: Watch the recording | See the slide deck
- July 26, 2022 – Coalition Members: Watch the recording | See the slide deck
- October 25, 2022 – Coalition Members: Watch the recording | See the slide deck
- January 24, 2023 – Coalition Members: Watch the recording | See the slide deck | Review of ACC/AHA Hypertension Guidelines slides
- April 25, 2023 – Coalition Members: Watch the recording | See the slide deck | Aledade Transitional Care Management slides
- July 25, 2023 – Coalition Members: Watch the recording | See the slide deck | Rick Mystrom Type 2 Diabetes and Excess Weight slides
- October 24, 2023 – Coalition Members: Watch the recording | See the slide deck
- January 23, 2024 – Coalition Members: Watch the recording | See the slide deck | Mountain Pacific CLAS Checklist
- April 23, 2024 – Coalition Members: Watch the recording | See the slide deck
Foundations of a Successful Coalition – Webinar Series
In this webinar, participants learn how to build a strong foundation for a successful coalition. The presentation digs into the goals of coalitions, how to form a mission and vision, achieving SMART (specific, measurable, achievable, relevant, time-bound) goals and the process of collaborative decision making.
- June 4 – Session 1: Watch the recording | See the slide deck
- June 18 – Session 2: Watch the recording | See the slide deck
- July 2 – Session 3: Watch the recording | See the slide deck
- July 16 – Session 4 (final): Watch the recording | See the slide deck
Quality Improvement Collaborative Kickoff Event – Webinar
Mountain-Pacific partners in communities across its region to support health care quality improvement. Watch this video to catch up on what’s new for coalition members, including the regional approach to group membership and the emphasis on engaging beneficiaries in their care.
Presentation by Mary Erickson, Mountain-Pacific Program Director
See May 7, 2020 Presentation
See May 14, 2020 Presentation
Pain Management in the Elderly – Webinar
Presentation by Steven Atkinson PA-C, MS
See Webinar Presentation
Top 10 Resources and Tools
Explore these top 10 lists covering various topics, providing actionable insights for optimal care and well-being in nursing homes, community centers and health care environments.
- Chronic Disease | View the Resource
Culturally and Linguistically Appropriate Services (CLAS) Checklist
Access tool here
Medication Management and Safety: A Guidebook for Older Adults
Developed by the Billings Care Transitions Coalition. This guidebook gives older adults tips to stay safe while using medications, how to be an advocate for your health when talking with a pharmacist or doctor and a section of frequently asked questions.
Access tool here
How to Use Your Medication List
This resource can help keep track of all current medications listed in one place.
Access resource
Addressing the Unique Care Needs of Older Adults | Access Tool Here
What Is an Age-Friendly Health System? | Access Tool Here
Pain Scale Card
This tool was developed to provide a standardized way to evaluate pain. This print-out provides two, two-sided cards with a pain assessment on one side and a visual pain scale tool on the other.
Adult Vaccination Schedule Resources
- State-specific calendars with a table of the recommended adult vaccination schedule
- Alaska | View poster
- Hawaii | View poster
- Montana | View poster
- Wyoming | View poster
- Customizable two-sided appointment card template with a table of the recommended adult vaccination schedule
Missoula, Montana
Billings, Montana
Bozeman, Montana
Helena, Montana
Kalispell, Montana
Coalition | Location | Contact |
---|---|---|
Billings Community Coalition | Billings, Montana | |
Northwest Montana Care Transitions Coalition | Kalispell, Montana | |
Western Montana Healthcare Coalition | Missoula, Montana | |
Helena Health Improvement Community Coalition | Helena, Montana | |
Southwest Montana Healthcare Coalition | Bozeman, Montana |
Basin, Wyoming
West, Wyoming
Northeast, Wyoming
Southwest, Wyoming
Central Wyoming
Coalition | Location | Contact |
---|---|---|
Casper Care Coalition | Central, Wyoming | |
Rock Springs | Southwest, Wyoming | |
Gillette | Northeast, Wyoming | |
Basin | West | |
Lander/Riverton | West |
Homer, Alaska
Alaska Diabetes Coalition
Alaska
Alaska
Coalition | Location | Contact |
---|---|---|
Alaska Diabetes Coalition | Statewide | |
South Kenai Peninsula Opioid Task Force | Homer | |
Take Heart Alaska | Statewide | |
Care Transitions Coalition | Statewide |
Saipan, Saipan, Northern Mariana Islands
Big Island, Hilo, Hawaii 96720
Honolulu, Hawaii
Kauai County, Hawaii
Maui County, Hawaii
West Oahu
Windward, Kailua, Hawaii 96734
Coalition | Location | Contact |
---|---|---|
Windward Community Partners | Windward, Hawaii | |
West Oahu Community Partners | West Oahu, Hawaii | |
Maui Community Partners | Maui, Hawaii | |
Big Island | Big Island, Hawaii | |
Honolulu Community Coalition | Honolulu, Hawaii | |
Saipan Community Care Transition Collaborative | Saipan, Northern Mariana Islands | |
Guam Diabetes Control Coalition | Guam | |
American Samoa | American Samoa | |
Kauai Community Care Partners | Kauai, Hawaii |