This Resource Library is intended as a listing of various resources that support use of the Care MAP tool.  Please note that each hyperlink will take you to the original source materials, website, worksheet, template, etc.

NACHC’s Risk Stratification Guide from its Value Transformation Network’s Action Guides

A clear and concise guide to help organizations understand the need to stratify their patient populations based on risk, define risk tiers, and consider practical strategies for how to risk stratify.

Case Scenario: AAFP’s Risk Stratification: A Two-Step Process for Identifying Your Sickest Patients

This Case Study provides an overview of how a family practice used a structured, algorithmic approach to determine their patients’ risk levels, and how this approach helped improve care team supports and patient experience.

Comagine’s Risk Stratification Guide

This risk stratification guide, developed by Comagine and the Indian Health Services, offers a step-by-step guide for identifying high-risk patients and also explores patient activation measures and other screening tools

Risk Stratification Using a Modified LACE Tool

This protocol, developed by Penobscot Community Health Care (PCHC), helps the organization assess patient risk so that their team can direct the level of services needed for patients with complex health conditions. Using a 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.

NACHC’s Models of Care Guide from its Value Transformation Network’s Action Guide

This guide from NACHC’s Value Transformation Network describes models of care considerations (staffing, clinical care services, care management, and partnership needs) for patients of varying risk tiers.

Leading the Way: Complex Care Management Program Overviews

From CHCF’s California Improvement Network, this publication provides a national scan of innovative and successful approaches to managing care for patients with complex, chronic conditions. You’ll find descriptions of staffing models, caseloads, care team engagement, and technology/resource needs.

Complex Care Budget Tool

This tool, developed by the Camden Coalition, helps estimate the expenses of running a complex care program. It’s a great reference for the types of expenses an organization might expect as they build and sustain a complex care service line.

SCAN Foundation: Cost Per Unit Calculation Tool

This tool provides an overview of fixed and variable costs, and how those inputs can help determine the costs of services in order to budget and set prices.

PHMI Initiative Business Case – Revenue Streams

This presentation, shared with participants in the Population Health Management Initiative, provides an overview of the multiple funding streams California’s for community health centers.

Funder Opportunity and Resource Map

This resource, part of the Camden Coalition’s Building the Value Case for Complex Care Toolkit, provides a framework for mapping potential sources of funding based on who you serve, how you present the case for complex care, and what metrics you track and report to demonstrate success.

Billing Resources

Another resource from the Camden Coalition’s Value Case for Complex Care Toolkit, this guide explores various billing codes that could be used for some complex care management services.

Complex Care Value Case Summary

This document from Camden Coalition’s Value Case for Complex Care shares common metrics for demonstrating the impact of complex care services. Also check out this Case Summary for an FQHC-specific model.

Assessing the Impact of Complex Care Models: Opportunities to Fill the Gaps

This guide from the Center for Health Care Strategies provides an overview of how 8 Advancing Integrated Models pilot sites demonstrated their impact through quality measures, patient experiences, and staff assessments.

Camden Coalition’s Complex Care Certificate Program

The Complex Care Certificate is a comprehensive introduction to the essential knowledge, skills, and attitudes required to provide complex care, including client engagement, care planning, trauma-informed care, and team-based practice. The Complex Care Certificate consists of nine self-paced, online courses that teach frontline health and social care staff how to build relationships to best support people with complex health and social needs. 13 CEUs are available upon completion.

Building the Value Case for Complex Care

This toolkit, designed by the Camden Coalition, includes a number of worksheets, resources, and case studies for building the value case for complex care services, including risk stratification, partnerships, stakeholder and asset assessment, value and ROI calculations, funding sources, and success stories

Camden Coalition’s Complex Care Startup Toolkit

The Camden Coalition’s Complex Care Startup Toolkit is a practical collection of guides, templates, and other tools to help you launch and grow a new complex care program.

The Better Care Playbook 

The Better Care Playbook is an online resource center for evidence-based and promising practices for improving complex care. The Playbook is meant to help health care stakeholders — including providers, health systems, health plans, community-based organizations, and policymakers — move evidence to action and accelerate adoption of best practices in complex care.

Health Begins’ ROI Calculator for Healthcare Partnerships to Address Social Needs

HealthBegins has developed and updated its Health Partnerships to Address Social Needs ROI Calculator. Their new “Quick Dive” Calculator will help project healthcare savings a healthcare organization might expect as a result of a social service investments, and can be a good reference for calculating cost savings.

SCAN Foundation’s ROI Calculator: The Business Case for Person-Centered Care

This return on investment (ROI) calculator was designed to assess the business case for person-centered care programs that serve older adults with chronic conditions. This is a great resource for organizations serving higher-proportions of Medicare patients.

PHM Initiative’s Business Case Tool

This Excel file, developed by the PHM Initiative as a part of its Business Case Guide, allows the user to make projections about its population health management service delivery and staffing to better understand the business case for building and expanding an organization’s population health management infrastructure.

CalAIM Budget Estimator Tool (Camden Coalition)

This Excel-based template provides a tool for estimating revenue and expenses for Enhanced Care Management (ECM) or Community Supports (CS) programs through Medi-Cal’s CalAIM transformation work. It can help organizations to model different potential scenarios and program offerings through CalAIM.