The Community Health Workers (CHWS) National Library has been compiled by our team from nationwide sources.

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Care Coordination Needs Assessment

Authors Indiana CMC CoIIN Leadership Team

Date 2021

Project CoIIN to Advance Care for Children with Medical Complexity

Keywords Indiana, Medical Home

This needs assessment is designed to assist care coordinators in rating their current knowledge and identifying areas of need that they would like to target in training over the next six months. The areas of need were primarily developed from this article: Schor E. An Almost Complete List of Services Used by Families and Children with Special Health Care Needs, Lucile Packard Foundation for Children’s Health, April 2019.

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A Global Perspective on Telemedicine: Addressing the Logistics of Coordination, Outcomes, and Satisfaction During a Pandemic

Authors Ivanora Alexander , Jonathan Borden, EdD, Patricia Purcell, MD, MBA

Date 2021

Project CoIIN to Advance Care for Children with Medical Complexity

Keywords Family Leadership in Systems, Kentucky

This poster presents changes Team Kentucky made to telemedicine services during the pandemic, their learnings about using telehealth, and strategies for addressing barriers. Originally presented at the AMCHP 2021 Conference.

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Virtual Care Team Conference (VCTC) Documentation Form

Authors OCSHCN

Date 2019

Project CoIIN to Advance Care for Children with Medical Complexity

Keywords Family Partnership at the Clinical Setting, Kentucky

This form is used to summarize questions addressed during the VCTC session and record planned follow-up and goals discussed.

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Family Virtual Care Team Conferences (VCTC) Brochure

Authors OCSHCN

Date 2019

Project CoIIN to Advance Care for Children with Medical Complexity

Keywords Family Partnership at the Clinical Setting, Kentucky

This brochure describes the VCTC process for families and outlines what will happen during shared care planning.

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Transition and You: Creating a Culture to Successfully Launch Our Patients to Adulthood with Compassion

Authors Tori Bahr, MD, Debbi Simmons Harris, MS, MA

Date 2021

Project CoIIN to Advance Care for Children with Medical Complexity

Keywords Family Partnership at the Clinical Setting, Minnesota

This recorded presentation describes Team Minnesota’s plan for helping patients transition from pediatric to adult care. It was originally presented to Gillette Children’s Specialty Healthcare.

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A Collaborative Model of Care between Primary Care and Inpatient Management Team

Authors Adam Rosenbloom, MD, MPH, Rahel Berhane, MD

Date 2021

Project CoIIN to Advance Care for Children with Medical Complexity

Keywords Medical Home, Texas

This presentation describes a unique relationship between the Children’s Comprehensive Care medical home and Dell Children’s Medical Center inpatient team to care for CMC. Originally presented at the Pediatric Academic Societies Meeting.

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The Parent Perspective Presentation

Authors Sherry Santa, Laura Warren

Date 2021

Project CoIIN to Advance Care for Children with Medical Complexity

Keywords Family Leadership in Systems, Texas

Presentation about the nonprofit agency Texas Parent to Parent and its services to multiple service coordinators in Texas that work at Managed Care Organizations across the state.

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An Innovative Care Coordination Delegation Model to Strengthen the Medical Home and Improve Outcomes

Authors Adam Rosenbloom, MD, MPH , Rahel Berhane, MD

Date 2021

Project CoIIN to Advance Care for Children with Medical Complexity

Keywords Medical Home, Texas

This slide deck describes the unique delegation arrangement that Children’s Comprehensive Care shares with BCBS STAR Kids (Managed Care Organization) to deliver service assessment and service coordination by the RN case manager at the medical home. The delegation funds non-billable case management services and integrates the assessment and service coordination within the medical home. Originally presented at the Pediatric Academic Societies Meeting.

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