Learning Collaborative

Care Coordination Toolkit

As a part of Minnesota’s Medicare Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration Project, a toolkit has been developed to assist health care homes and primary care clinics in serving the complex population of seniors and persons with disabilities.

Health Care Home Care Coordination: Toolkit for Working with Persons with Complex Needs and Older Adults (PDF: 41pages/1MB)

Comprehensive Patient Assessment (PDF: 1 page/280KB)


The resources and guides selected for inclusion in this toolkit have been found to be best practices in the fields of senior and disability care.

The toolkit begins with an introduction and a linkable table of contents.

Next, the toolkit includes a practical guide to components of a “Comprehensive Patient Assessment.”

Following the assessment is an assortment of resources, tools, and guides intended to supplement existing assessments, care plans, and processes with specialized tools for engaging with community-based supports and services needed within an ‘extended care plan.’ To help users navigate the document, the resources are divided into 12 different categories.


We want this toolkit to be responsive to your needs. If you have any comments or suggestions on the toolkit, please fill out our feedback survey.


The toolkit was developed through the efforts of a formal Resource Workgroup of the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration.

Updated Friday, January 09, 2015 at 01:36PM