Case summariesVignettes, profiles and testimonial videos

ToolkitsImplementation guides and other documents with extensive resources included

Staff trainingTutorials, training manuals, etc.

  • Staff training

    Patient Navigator Certificate Program Goals and Objectives

    This single page document lays out the Goals and Objectives of the Sonoma State University Patient Navigator Certification Program and identifies the core components of the role and the skill set that needs to be learned to succeed as a Patient Navigator.


  • staff

    Self-Management Support Training for Medical Assistants

    Union Health Center developed a robust training curriculum for MAs to take on expanded roles in patient education. Self-management support is a major component of the training, including goal setting, reflective listening, motivational interviewing, and relationship-building. The MA curriculum consists of PowerPoint slides, in-person exercises, and homework assignments. To receive a pdf of the MA training curriculum, please contact Audrey Lum, RN, MPA, at

Role featuresJob descriptions, career ladders and other HR materials

  • Role features

    Patient Navigator Job Description

    This Position Description from West County Health Centers summarizes the role of the Patient Navigator as an advocate for high-need and high-risk patients, describes the duties performed by the position, and the minimum requirements for filling the role.

WorkflowTemplates, flow sheets and mapping aids

  • Workflow

    Flowsheet for Medical Assistant Diabetes Management (MADM) Visit

    This flowsheet for the Medical Assistant Diabetes Management (MADM) visit steps through the identification, scheduling, and order review steps that occur before the visit, as well as the actions to be conducted in the visit itself.

  • Workflow

    Integrating patient goals into the practice EHR

    See how one LEAP site has added several templates into the EHR in order to effectively provide self-management support to patients. There are fields for patient goals that are regularly used by care team members, especially providers and health coaches.

Patient materialsAction plans, brochures, team cards, welcome letters

  • Patient materials

    Self-Management Action Plan

    This document contains both a blank and sample action plan in the format used by High Plains Community health Center of Colorado.

  • Patient materials

    Self-Management Action Plan

    This Self Management goal setting tool from neighborhood Family practice in Ohio can be printed in English and Spanish, and includes a listing of goals that the patient can choose to work toward.

  • Patient materials

    Self-Management Action Plan

    This one page, fill-in-the-blank example of a Self Management Action Plan contract is from West County health Center in California


  • Video

    Health Coaching (Action Plans): Techniques to Deliver Patient-Centered Care

    This video from the UCSF Center for Excellence in Primary Care examines how to engage patients in health behavior change, as well as coaching techniques for effective medication adherence.