Care Coordination

Last Reviewed: March 10, 2016

What You’ll Learn

  1. Define care coordination
  2. Define the clinician’s role in care coordination
  3. Identify patients and caregivers who will most benefit from care coordination
  4. Identify strategies for embedding care coordination into practice

What You’ll Earn

CAPC members can earn the following free continuing education credits:

Case Management: 1.00 CE
Medicine: 0.75 CME
Nursing: 1.00 CNE
Social Work: 1.00 CE (NYSED)
Social Work: 1.00 CE (NASW)

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Tools & Resources

MEMBERS ONLY locked

Network Assessment for Care Coordination: Interview Guide

Last Updated: January 29, 2019

A structured process for assessing gaps the care coordination needs of patients and organizational stakeholders. Center to Advance Palliative Care, 2016.

MEMBERS ONLY locked

Course References: Care Coordination

Last Updated: January 29, 2019

Course citations. Center to Advance Palliative Care, 2016.

Advanced Illness Management (AIM) Model

Last Updated: January 29, 2019

A model for addressing gaps in care for patients living with serious illness, including safe care transitions. American Hospital Association, 2012.

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Area Agency on Aging Services

Last Updated: January 29, 2019

Area Agencies on Aging (AAAs) provide a range of aging services to enable older adults to “age in place” in their homes and communities.

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Reducing Care Fragmentation: A Toolkit for Coordinating Care

Last Updated: January 29, 2019

A publication by the California Health Care Foundation. Includes case studies, and guidance for improving care coordination in primary care.

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Care Coordination Fundamentals: Teacher Guide

Last Updated: January 29, 2019

Guidance on training and implementation of patient navigation and care coordination. 1199SEIU Training & Employment Fund and Primary Care Development Corporation, 2017.

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Case Managment Credentialing Entities and Eligibility Requirements

Last Updated: January 29, 2019

Guidance from the Case Management Society of America on case management certification options.

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Commission for Case Manager Certification (CCMC) Issue Briefs

Last Updated: January 29, 2019

Each publication of The Commission's Issue Briefs covers topics that are timely and relevant for today’s professional case manager.

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The Care Transitions Program(R)

Last Updated: January 29, 2019

A leading national model for improving care transitions led by Dr. Eric Coleman.

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Chronic Care Management Services

Last Updated: January 29, 2019

Department of Health and Human Services, Centers for Medicare and Medicaid Services.

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National Quality Forum (NQF) Care Coordination Measures

Last Updated: January 29, 2019

Guidance from the NQF on measures for care coordionation.

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Optimizing Billing Practices

Last Updated: March 4, 2019

Toolkit with billing and coding best practices for palliative care services delivered in the hospital or the community.

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Andrew E. Esch, MD, MBA. Consultant, Center to Advance Palliative Care.

Lolita Melhado, MSN, ARNP, FNP-BC. Family Nurse Practitioner/Palliative Care, Gulf Coast Medical Center - Lee Memorial Health System.

Constance Dahlin, MSN, ANP-BC, ACHPN, FPCN, FAAN. Consultant, Center to Advance Palliative Care.

Elizabeth Mann, MD. Fellow, Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai.

Contact information: For technical questions about online activity or continuing education credits, contact membership@capc.org or 212-201-2674.

Provided by the Icahn School of Medicine at Mount Sinai.

The Courses

Supporting the Family Caregiver: The Burden of Serious Illness

Assessing and supporting caregivers of people with serious illness.

View all courses in the unit

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