Care Coordination Skill

Facilitate multi-provider care coordination with structured handoff protocols, referral management, and care team communication. Designed to ensure seamless transitions across healthcare settings.

Overview

This skill enables clinical AI agents to:

• Generate provider-to-provider handoff documentation
• Create referral letters with appropriate clinical detail
• Coordinate care team task assignments
• Document transitions of care
• Track follow-up scheduling and compliance
• Support chronic care management coordination

Handoff Communication

SBAR Framework

Structured handoff using SBAR:

S - Situation What is happening with the patient right now?

B - Background What is the clinical context?

A - Assessment What do I think the problem is?

R - Recommendation What do I recommend?

SBAR Handoff Template

PATIENT HANDOFF COMMUNICATION

Date/Time: [Handoff time]
From: [Sending provider/team]
To: [Receiving provider/team]

SITUATION:
Patient: [De-identified ID]
[Age range]-year-old [sex] admitted for [primary reason]
Current status: [Stable/Unstable/Improved/Declining]
Immediate concerns: [List any urgent issues]

BACKGROUND:
Admission Date: [Date]
Primary Diagnosis: [Diagnosis]
Key History: [Relevant past medical history]
Allergies: [List or NKDA]
Code Status: [Full code/DNR/DNI]

Key Events This Shift:
• [Event 1]
• [Event 2]

Current Medications: [Highlight recent changes]
Recent Labs/Studies: [Significant results]

ASSESSMENT:
[Clinical assessment of current condition]
Active Problems:
1. [Problem] - [Current status]
2. [Problem] - [Current status]

RECOMMENDATION:
Priority Tasks:
1. [Task with timing]
2. [Task with timing]

Pending Items:
• [Pending labs/consults/imaging]

Anticipated Issues:
• [Potential problems to watch for]

Family/Contact: [Available/Needs update/Specific concerns]

Questions/Clarifications:
[Opportunity for receiving provider to ask questions]

Handoff acknowledged by: [Receiving provider]
Time: [Time of acknowledgment]

Referral Management

Referral Letter Template

CONSULTATION REQUEST

Date: [Date]
To: [Specialist name/department]
From: [Referring provider]
Priority: [Routine/Urgent/Emergent]

RE: [De-identified patient ID]
DOB Range: [Age range]

REASON FOR REFERRAL:
[Clear, concise reason for consultation]

CLINICAL SUMMARY:

History of Present Illness:
[Brief summary of current problem prompting referral]

Relevant Medical History:
• [Condition 1]
• [Condition 2]

Current Medications:
[Relevant medications]

Allergies: [List or NKDA]

Previous Workup:
[Labs, imaging, or tests already performed]

Physical Examination Findings:
[Relevant exam findings]

ASSESSMENT:
[Working diagnosis or differential]

SPECIFIC QUESTIONS FOR CONSULTANT:
1. [Question 1]
2. [Question 2]

REQUESTED SERVICES:
□ Evaluation and recommendations
□ Comanagement
□ Assume primary care of condition
□ Procedure: [Specify]

URGENCY JUSTIFICATION (if urgent/emergent):
[Explain why expedited evaluation needed]

CONTACT INFORMATION:
[Referring provider contact for questions]

Please send consultation report to: [Address/fax/portal]

Thank you for seeing this patient.

[Referring provider signature]

Referral Tracking

Track referral status:

• Referral sent date
• Appointment scheduled (Y/N)
• Appointment date
• Report received (Y/N)
• Recommendations implemented

Care Team Coordination

Care Team Roster

Document care team members and roles:

CARE TEAM ROSTER

Patient: [De-identified ID]

PRIMARY CARE:
• PCP: [Name/Clinic] - [Contact]
  Role: Overall care coordination, preventive care

SPECIALISTS:
• Cardiology: [Name] - [Contact]
  Role: Heart failure management
  Last visit: [Date]
  Next visit: [Date]

• Endocrinology: [Name] - [Contact]
  Role: Diabetes management
  Last visit: [Date]

OTHER TEAM MEMBERS:
• Care Manager: [Name] - [Contact]
• Pharmacist: [Name] - [Contact]
• Social Work: [Name] - [Contact]
• Home Health: [Agency] - [Contact]

FAMILY/CAREGIVER:
• Primary Contact: [Relationship] - [Phone]
• Emergency Contact: [Relationship] - [Phone]

PREFERRED PHARMACY:
[Pharmacy name, address, phone]

COMMUNICATION PREFERENCES:
• Patient prefers: [Phone/Text/Portal/In-person]
• Best time to reach: [Morning/Afternoon/Evening]
• Language: [English/Hindi/Other]
• Interpreter needed: [Yes/No]

Care Team Meeting Notes

CARE TEAM MEETING SUMMARY

Date: [Date]
Attendees: [List participants and roles]
Patient Present: [Yes/No]

CURRENT STATUS REVIEW:
[Brief summary of patient's current condition]

DISCUSSION TOPICS:

1. [Topic 1]
   • Current status: [Status]
   • Discussion: [Key points]
   • Decision: [What was decided]
   • Responsible: [Who will do what]

2. [Topic 2]
   • Current status: [Status]
   • Discussion: [Key points]
   • Decision: [What was decided]
   • Responsible: [Who will do what]

ACTION ITEMS:
┌────────────────┬──────────────┬───────────┐
│ Task           │ Responsible  │ Due Date  │
├────────────────┼──────────────┼───────────┤
│ [Task 1]       │ [Person]     │ [Date]    │
│ [Task 2]       │ [Person]     │ [Date]    │
└────────────────┴──────────────┴───────────┘

NEXT MEETING: [Date/Time]

FOLLOW-UP COMMUNICATION:
• Patient/Family notified of decisions: [Yes/No]
• Next steps communicated to: [List]

Transition of Care

Hospital to Home Transition

TRANSITION OF CARE SUMMARY

Patient: [De-identified ID]
Transition Type: Hospital to Home
Discharge Date: [Date]
Receiving Provider: [PCP name]

CLINICAL SUMMARY:
[Brief summary of hospitalization and discharge condition]

ACTIVE DIAGNOSES AT DISCHARGE:
1. [Diagnosis] (ICD-10: [code])
2. [Diagnosis]

DISCHARGE MEDICATIONS:
[Complete reconciled medication list]
CHANGES from admission: [List new/changed/stopped]

PENDING ITEMS:
• Labs pending: [List with expected results]
• Studies pending: [List]
• Consultations pending: [List]

FOLLOW-UP REQUIREMENTS:
• PCP: Within [X] days - [Purpose]
• Specialist: [Type] within [X] days - [Purpose]
• Labs: [Test] by [Date]

RED FLAGS - RETURN TO HOSPITAL IF:
• [Warning sign 1]
• [Warning sign 2]
• [Warning sign 3]

FUNCTIONAL STATUS:
• Mobility: [Ambulatory/Assist/Wheelchair]
• ADLs: [Independent/Assist needed]
• Cognition: [Baseline/Impaired]

HOME SERVICES ARRANGED:
• Home Health: [Yes/No] - [Services]
• DME: [Equipment ordered]
• PT/OT: [Arranged]

PATIENT/FAMILY EDUCATION COMPLETED:
□ Medications reviewed
□ Warning signs explained
□ Follow-up appointments scheduled
□ Contact numbers provided

COMMUNICATION SENT TO:
□ PCP via [method]
□ Specialist via [method]
□ Home health agency
□ Pharmacy

[Discharging provider signature]

Warm Handoff Protocol

For real-time transitions:

1. Introduce - Connect patient with receiving provider
2. Summarize - Brief overview in patient's presence
3. Confirm - Patient confirms understanding
4. Questions - Opportunity for questions
5. Contact - Provide callback information

Chronic Care Management

Care Plan Summary

CHRONIC CARE MANAGEMENT PLAN

Patient: [De-identified ID]
Effective Date: [Date]
Review Date: [Next review date]

ACTIVE CONDITIONS:
1. [Condition] - [Status: Controlled/Uncontrolled]
2. [Condition] - [Status]

CARE GOALS:
Short-term (3 months):
1. [Goal with measurable target]
2. [Goal with measurable target]

Long-term (12 months):
1. [Goal with measurable target]

MONITORING SCHEDULE:
┌─────────────────┬────────────┬────────────┐
│ Parameter       │ Frequency  │ Target     │
├─────────────────┼────────────┼────────────┤
│ HbA1c           │ Quarterly  │ <7%        │
│ Blood Pressure  │ Monthly    │ <130/80    │
│ Weight          │ Weekly     │ Maintain   │
└─────────────────┴────────────┴────────────┘

SELF-MANAGEMENT TASKS:
Daily:
• [Task 1]
• [Task 2]

Weekly:
• [Task]

CARE TEAM RESPONSIBILITIES:
• PCP: [Specific responsibilities]
• Specialist: [Specific responsibilities]
• Care Manager: [Specific responsibilities]
• Patient: [Self-management responsibilities]

EMERGENCY PLAN:
If [situation], then [action]
If [situation], then [action]

BARRIERS TO CARE:
• [Barrier 1] - Plan: [Mitigation]
• [Barrier 2] - Plan: [Mitigation]

NEXT REVIEW: [Date]

Follow-up Scheduling

Follow-up Recommendations

Generate appropriate follow-up based on:

• Diagnosis and severity
• Treatment changes
• Patient stability
• Guideline recommendations

Standard Follow-up Intervals

| Scenario | Recommended Follow-up | |----------|----------------------| | Medication initiation | 2-4 weeks | | Dose adjustment | 2-4 weeks | | Stable chronic disease | 3-6 months | | Acute illness resolved | 1-2 weeks PRN | | Post-hospitalization | 7-14 days | | High-risk patient | Weekly-monthly |

Communication Templates

Provider-to-Provider Message

SECURE MESSAGE TO PROVIDER

To: [Receiving provider]
From: [Sending provider]
Re: [Patient de-identified ID]
Priority: [Routine/Urgent]

Dear [Colleague],

I am writing regarding our mutual patient, [brief identifier].

[Body of message - clinical question, update, or coordination need]

Please advise on [specific question or request].

I can be reached at [contact] if you need additional information.

Thank you,
[Sending provider]

Patient Outreach Message

PATIENT OUTREACH

Date: [Date]
Patient: [De-identified ID]
Outreach Type: [Phone/Portal/Letter]
Reason: [Follow-up/Results/Reminder]

Attempted contact: [Time]
Result: [Reached/Voicemail/No answer]

If reached:
• [Summary of conversation]
• Patient response: [Agreed/Declined/Questions]
• Action taken: [Next steps]

If not reached:
• Voicemail left: [Yes/No]
• Alternative contact attempted: [Yes/No]
• Next attempt scheduled: [Date/Time]

Documentation complete: [Yes]

Usage Instructions

1. Identify Coordination Need

Determine type of coordination:

• Provider handoff
• Specialist referral
• Care team meeting
• Transition of care
• Chronic care planning

2. Gather Required Information

Collect:

• Clinical summary
• Active medications
• Recent test results
• Care team contacts
• Patient preferences

3. Generate Documentation

Create appropriate document:

• Select template
• Fill required fields
• Include actionable items
• Specify responsibilities

4. Execute Communication

• Send to appropriate recipients
• Confirm receipt
• Document in patient record
• Track for follow-up

Integration with TherapyPod

This skill integrates with:

• Treatment Plans - Coordinates implementation
• Clinical Notes - Documents coordination activities
• Patient Triage - Routes to appropriate care team
• ClinEval Benchmark - Escalation quality validation

References

• See references/handoff-protocols.md for communication standards
• See references/transition-checklists.md for transition requirements
• See references/ccm-guidelines.md for chronic care management