“Reducing Care Fragmentation: A Toolkit for Coordinating Care” offers practical strategies and clinical resources designed to pave the way towards better patient transitions and referrals.
Our Resources
Team Up for Health
The 42-month Team Up for Health initiative, funded by The California HealthCare Foundation, brought patients, their families and clinical teams together to define and test processes leading to better self-management of chronic conditions.
Building Teams in Primary Care
Building Teams in Primary Care, by Tom Bodenheimer, is a report to the California Healthcare Foundation with case studies of 15 diverse practice environments. Dr. Bodenheimer is the Chair of LEAP’s National Advisory Committee.
Partnering in Self-Management Support: A Toolkit for Clinicians
MacColl Senior Researcher Judith Schaefer, MPH is co-author of “Partnering in Self-Management Support: A Toolkit for Clinicians”, an introduction to supporting and collaborating with patients and their families in the daily management of chronic conditions.
The Primary Care Team: Learning from Effective Ambulatory Practices (the LEAP Project)
The Primary Care Team: Learning from Effective Ambulatory Practices (the LEAP Project) visited 30 primary care practices that use health professionals and other staff in ways that maximize access to their services, and is cataloging the results. Funding is provided by the Robert Wood Johnson Foundation.
Implementing Chronic Care and Business Strategies in the Safety Net: A Coaching Manual
Containing a coaching framework and tools to support clinical teams as they implement the Chronic Care Model, “Implementing Chronic Care and Business Strategies in the Safety Net: A Coaching Manual” was written for practice facilitators in community health centers.
Coach Medical Home
Coach Medical Home is a web-based curriculum organized into six modules that was developed through the SNMHI initiative. This curriculum provides coaches with practical handbooks and presentations for immediate support in their transformation efforts
Cost estimates for operating a primary care practice facilitation program
MacColl Director Michael Parchman shows in 2013 that practice facilitation costs can be covered by preventing 2 hospitalizations or readmissions annually. Read “Cost estimates for operating a primary care practice facilitation program”.
The Safety Net Medical Home Initiative
The Safety Net Medical Home Initiative engaged Medical Home Facilitators to coach 65 primary care practices towards becoming patient-centered medical homes.
Improving Chronic Illness Care
The Improving Chronic Illness Care website helps health care systems change the care they provide for chronically ill patients, with a special emphasis on underserved populations. The site is a trusted destination for researchers, clinicians, and other stakeholders seeking evidence-based quality improvement materials.