Care Coordination Roles Planning Matrix TemplateHow to Use: See Care Coordination Roles Planning Matrix in the CCC Toolkit.
Care Coordination Role
P = primary responsibilityS = secondary or support responsibility
Care Coordination Activity CCC
prog
ram
man
ager
Care
coo
rdin
ator
Soci
al w
orke
r
Heal
th p
lan
case
man
ager
Fron
t-de
sk st
aff/r
ecep
tioni
st
Back
-offi
ce st
aff/s
ched
uler
Med
ical
ass
istan
t or L
PN
Prov
ider
—M
D
Prov
ider
—PA
Prov
ider
—N
P
Regi
ster
ed N
urse
Men
tal h
ealth
pro
fess
iona
l
Nut
rition
ist
Heal
th e
duca
tor
Com
mun
ity re
sour
ce d
irect
or
Com
mun
ity re
sour
ce st
aff
Qua
lity
impr
ovem
ent d
irect
or
ED re
gist
ratio
n st
aff
ED m
anag
er
Clin
ic m
anag
er
Heal
th c
oach
Phar
mac
ist
<oth
er c
are
coor
dina
tion
role
>
<oth
er c
are
coor
dina
tion
role
>
Add
colu
mns
as n
eede
d…
Identify eligible patients
Develop patient recruitment strategy
Develop CCC brochure and/or videos
Recruit patients to program
Schedule initial face-to-face CC visit
Schedule follow-up face-to-face CC visits
Prepare CCC plan
Prepare patient care plan (for Pt)
Prepare patient action plan (with Pt)
Conduct medication reconciliation
Develop referral tracking/follow-up process
Schedule patient referrals
Track/follow-up on patient referrals
Prepare and review Pt health diary
Develop condition-specific education material
Provide condition-specific education (with Pt)
Section 2.5.1 Plan—Care Coordination Roles Planning Matrix Template - 1
Care Coordination Role
P = primary responsibilityS = secondary or support responsibility
Care Coordination Activity CCC
prog
ram
man
ager
Care
coo
rdin
ator
Soci
al w
orke
r
Heal
th p
lan
case
man
ager
Fron
t-de
sk st
aff/r
ecep
tioni
st
Back
-offi
ce st
aff/s
ched
uler
Med
ical
ass
istan
t or L
PN
Prov
ider
—M
D
Prov
ider
—PA
Prov
ider
—N
P
Regi
ster
ed N
urse
Men
tal h
ealth
pro
fess
iona
l
Nut
rition
ist
Heal
th e
duca
tor
Com
mun
ity re
sour
ce d
irect
or
Com
mun
ity re
sour
ce st
aff
Qua
lity
impr
ovem
ent d
irect
or
ED re
gist
ratio
n st
aff
ED m
anag
er
Clin
ic m
anag
er
Heal
th c
oach
Phar
mac
ist
<oth
er c
are
coor
dina
tion
role
>
<oth
er c
are
coor
dina
tion
role
>
Add
colu
mns
as n
eede
d…
Conduct health risk assessment(s)
Conduct environmental risk assessment(s)
Complete Pt care coordination variance log
Provide mental health crisis intervention
Monitor vital signs and report out-of-range
Develop wellness services plan
Develop patient self-management tools
Conduct self-management (with Pt)
Develop supportive communications tools
Develop shared-decision-making tools
Conduct shared-decision-making (with Pt)
Develop remote monitoring tools & process
Develop discharge CC checklist
Use discharge CC checklist
Develop/manage provider resource directory
Develop/manage community resource directory
Develop patient communication plan
Conduct pharmacist outreach
Conduct community outreach
Section 2.5.1 Plan—Care Coordination Roles Planning Matrix Template - 2
Care Coordination Role
P = primary responsibilityS = secondary or support responsibility
Care Coordination Activity CCC
prog
ram
man
ager
Care
coo
rdin
ator
Soci
al w
orke
r
Heal
th p
lan
case
man
ager
Fron
t-de
sk st
aff/r
ecep
tioni
st
Back
-offi
ce st
aff/s
ched
uler
Med
ical
ass
istan
t or L
PN
Prov
ider
—M
D
Prov
ider
—PA
Prov
ider
—N
P
Regi
ster
ed N
urse
Men
tal h
ealth
pro
fess
iona
l
Nut
rition
ist
Heal
th e
duca
tor
Com
mun
ity re
sour
ce d
irect
or
Com
mun
ity re
sour
ce st
aff
Qua
lity
impr
ovem
ent d
irect
or
ED re
gist
ratio
n st
aff
ED m
anag
er
Clin
ic m
anag
er
Heal
th c
oach
Phar
mac
ist
<oth
er c
are
coor
dina
tion
role
>
<oth
er c
are
coor
dina
tion
role
>
Add
colu
mns
as n
eede
d…
<other care coordination activity>
<other care coordination activity>
<other care coordination activity>
<other care coordination activity>Add rows as needed . . .
Section 2.5.1 Plan—Care Coordination Roles Planning Matrix Template - 3