Publications

ToolkitsImplementation guides and other documents with extensive resources included

Role featuresJob descriptions, career ladders and other HR materials

  • Role features

    Care Coordinator Job Responsibilities

    Learn about the responsibilities of the care coordinator at one LEAP site. Working with a nurse care manager, the MA care coordinator supports care management focused on the highest-risk patients.

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  • Role features

    Nurse Care Manager Job Responsibilities

    Learn about the responsibilities of the nurse care manager at one LEAP site. The nurse care manager works with an MA care coordinator to provide care management focused on the highest-risk patients.

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  • Role features

    Health Coach Job Description

    Here is a job description of an MA health coach that is part of the centralized care management team at Penobscot Community Health Care.

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  • Role features

    Care Manager Job Description

    Here is a job description of a nurse care manager (RN) that is part of the centralized care management team at Penobscot Community Health Care.

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Webinar and power point presentations

  • Webinar and power point presentations

    Models of Complex Care Management

    Learn how 4 LEAP sites approach care management. Notice that these are very different organizations serving different patient population needs.

Staff trainingTutorials, training manuals, etc.

  • Staff training

    Transitions of Care Management (TCM Code) Tutorial

    Learn how one LEAP site has trained team members on coding to reimburse services under the new Transition of Care Management code.

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  • Staff training

    High-Risk Case Management Overview

    Learn about the high-risk case management approach at one LEAP site, in determining how to best allocate different types of team-based care to patients based on their level of risk and need. You can find protocol related to the high-risk case management services in our collection of tools in this topic

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  • Staff training

    Case Conference Description

    Learn about one LEAP site's approach to multidisciplinary case conference reviews of patients in the complex care management program. The nurse care manager invites relevant clinical experts, including the provider, MA, behavioral health specialist, or pharmacist, depending on the cases being discussed. Each team member brings different types of insight and suggestions for making improvements to the patient's care plan.

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  • Staff training

    Complex Case Management Care Plan

    Learn about one LEAP site's approach to multidisciplinary case conference reviews, by looking at the care plan notes from one of these sessions for patients in the complex care management program. The nurse care manager invites relevant clinical experts, including the provider, MA, behavioral health specialist, or pharmacist, depending on the cases being discussed. Each team member brings different types of insight and suggestions for making improvements to the patient's care plan.

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Clinical protocolStanding orders, risk stratification forms and hospital transition protocols

  • Clinical protocol

    Risk Stratification using a modified LACE Tool

    See how one LEAP site, Penobscot Community Health Care (PCHC), risk stratifies patients to direct the level of services needed for patient with complex health conditions. The highest risk patients are admitted to a robust complex care management program, then assessed using the modified LACE tool. PCHC developed a workflow involving the MA Health Coach, RN Care Manager, and social worker who are part of the complex care management team.

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  • Clinical protocol

    Hospital Pre-Discharge Virtual Patient Interview Protocol

    Learn how one LEAP site connects with patients while still in the hospital, to begin coordinating the transition. West County Health Centers uses technology to facilitate a more personal connection when possible.

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  • Clinical protocol

    Care management discharge criteria

    Learn about the criteria that one LEAP site uses to discharge patients from care management, once they have reached their clinical goals.

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  • Clinical protocol

    Hospital Transition Intake

    See protocol used by nurse care managers at one LEAP site during a transition follow-up after patients are discharged from the hospital.

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  • Clinical protocol

    Transition Care Clinical Protocol

    See protocol used by nurse care managers at one LEAP site for patient care transitions.

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  • Clinical protocol

    RN ER Case Management Clinical Protocol

    See protocol used by nurse care managers at one LEAP site to follow-up after patients have an ER visit.

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  • Clinical protocol

    Complex Care Management Intake Clinical Protocol

    See protocol used by nurse care managers at one LEAP site when patients are admitted into the high-risk case management program.

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  • Clinical protocol

    RN Complex Care Management Case Conference Clinical Protocol

    See protocol used by nurse care managers at one LEAP site to conduct a multidisciplinary case conference review of patients in the complex care management program who need a new or revised care plan. The Nurse care manager invites relevant clinical experts, which includes the provider, MA, behavioral health specialist, or pharmacist, depending on the cases being discussed.

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WorkflowTemplates, flow sheets and mapping aids

  • Workflow

    Hospital Pre-Discharge Virtual Patient Interview Workflow

    Learn how one LEAP site connects with patients while still in the hospital, to begin coordinating the transition. West County Health Centers uses technology to facilitate a more personal connection when possible.

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  • Workflow

    Hospital Transition Overview

    Learn about one LEAP site's organizational approach to care transitions in this document, which reflects the commitment to collaborating with all of the hospitals where a majority of their patients seek care and having a process for timely information exchange with each hospital. Leadership, providers, and nurses all have a critical role in creating and maintaining processes so that patients experience a smooth transition across care settings.

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