Care Coordination

Behavioral Health

2016 Health Report Card: Mental Health
ACE Calculator
AUDIT-C Alcohol Screen
Behavioral Health as a Strategy for Population Health
Core Competencies for Behavioral Health Providers Working in Primary Care
Depression Management Toolkit
Early Childhood Mental Health Toolkit
Implementation Guide Behavioral Health Integration
Integrated Mental Health
Key Messages for the IBH Journey
The Role of Behavioral Health in Optimizing Care for Complex Patients

Care Compacts

Care Compact Collaborative Care Management Best Practices
Care Compact Example by Family Medicine and Emergency Department
Care Compact Example by Peak Professionals
Care Compact Example by Western Colorado Pediatric Associates
Care Compact Example by Western Valley Family Practice
Care Compact Template by RMHP
Care Compact-Collaborative Guidelines Example by A Kidz Clinic
Care Compact-Collaborative Guidelines Example by Foresight Family Physicians and Western Orthopedics & Sports Medicine
Care Compacts - Specialty Provider Collaborative Care Management
Hospital/SNF and Provider Compact Guidelines

Care Coordination

Care Coordination Measures Atlas
Coordinating Care in the Medical Neighborhood
Implementation Guide Care Coordination
Measuring Care Coordination
Pediatric Co-Management Letter and Agreement
Referral Tracking Template

Care Management

Care Management Policy & Procedure Example by Glenwood Medical Associates
Colorado MOST Form
Complex Care Management Toolkit
Counting Carb and Meal Planning- English
Counting Carb and Meal Planning- Spanish
FAQ Transitional Care Management
Hypertension Brochure
Hypertension Provider Toolkit
Readmission Tool

Care Plans

Advanced Care Planning Group Visit Implementation Manual
BioPsychoSocial Assessment
Can Personalized Care Planning Improve Primary Care
Care Plan Audit Tool by RMHP
Care Plan Template
Diabetes Passport
Engaging Patients in Collaborative Care Plans
Sample Diabetes Patient Care Plan

Care Transitions

Care Team Checklist
Community Preparedness Checklist
Pediatric Transition to Adult Care Guide
Transitional Care Management 30-Day Worksheet


Cultural Competence Self-Assessment
Language Services Action Kit
Motivational Interviewing- Definition, Principles & Approach
Patient-centered Interactions
The Conversation Project Brochure
The Conversation Project Starter Kit

Disease Management

Low Blood Sugar- Spanish
Measuring Orthostatic Blood Pressure
Organized, Evidence-Based Care

Geriatric Assessments

A Geriatric Evaluation for Transitions
ADL for Geriatrics
Geriatric Health Questionnaire

Group Visits

Diabetes Group Visit Checklist
Diabetic Clinic Evaluation

High Risk Patient Management

Adult Risk Stratification Tool Example by Mercy Family Medicine
Behavioral Health Risk Stratification Tool Example by Roaring Fork School Based Health Center
Changing Unhealthy Behaviors Tool
CUPS Risk Assessment Scoring Tool
Pediatric Risk Stratification Tool by Mercy Family Medicine
Risk Stratification Example by Kettering Physician Network
Risk Stratification Protocol Example by Mercy Family Medicine
Risk Stratification Tool by Dino-Peds
Risk Stratification Tool Example by Uncompahgre Medical Center

Medical Neighborhood

Can we lower medical costs by giving the neediest patients better care?
Coordinating Care in the Medical Neighborhood
Medical Neighborhood work plan
Primary Care Specialty Care Compact
Resource Library Template
Systems of Care/PCMH Initiative
The Principles of the Care Coordination Agreements

Medication Management

Comprehensive Medication Management in Team-Based Care
Medication Chart
Medication Log
Medication Tracking Diary
Medication Worksheet

Remote Access

Applying Behavior Change Principles
Business Impact of Effective Remote Care Management
Care Innovations Guide
Cost Control for Chronic Conditions
Improve Your MA Star Ratings
Successful Remote Care Management Implementations


Addressing Cost-Quality-Access with Innovative Telehealth Technology
AMA Steps Forward Adopting Telemedicine
CMS Telehealth Factsheet