Team-Based Care Coordination: Understand, Communicate, and Work At The Top Of Your Scope

Series meets Thursday (Weekly) from 8:00 AM to 9:00 AM MST


The Patient Navigator Training Collaborative (PNTC) and ECHO Colorado are partnering on a study to evaluate how our trainings improve team-based care coordination skills.  This project is designed to learn more about the effectiveness of these trainings in increasing self-efficacy, knowledge, attitudes, and skills related to team-based care coordination among participants.

How do I participate?

Register for PNTC’s Care Coordination Online Course or the Care Coordination ECHO Learning Series. (It is strongly recommended to participate in the course before the learning series.) You will have the opportunity to join the study during registration. These courses will be offered quarterly through 2019. You must be a Colorado resident to participate.

How much time will it take?

In addition to attending each session of the course or learning series, you will be asked to complete a 10-15 minute pre/post survey and a 30-minute pre/post assessment with a “team member” actor, via Zoom web conferencing. It will take about 1.5 hours total. You will receive a link for the survey before and after the learning opportunity and the pre/post assessments will be scheduled at a time that works for you.

Why should I participate?

You will earn online Visa gift cards for your time for each portion of the study you complete, up to $80 for full participation. You will also receive the results of your assessment at the end of the study. The assessment results will identify areas of strengths and improvement that you can use to improve your skills.

Questions? Email Michelle Guthrie at


To improve the health and quality of care for patients with chronic disease by providing care coordinators with foundational knowledge and practice opportunities for prevention and management strategies.


This series is offered in partnership with the Patient Navigator Training Collaborative (PNTC), the Rocky Mountain Public Health Training Center (RMPHTC) and the Care Coordination Central (CCC).


-Compare and contrast the role of the care coordinators from other roles within the care team

-Discuss the care coordinator skillset

-Describe the role of the care coordinator in the screen and panel management

-Use evidence based care coordination tool to prioritize patients according to patient needs

-Use an assessment checklist to assess patients with regard to medical, mental health, and social determinants of health

-Evaluate your current assessment checklist for comprehensiveness in screening patients for medical and mental health conditions, and social determinants of health

-Discuss culturally sensitive questions to assess patients for social determinants of health issues

-Use interview skills to assess patient needs

-List behavioral support strategies for self-management support

-Apply motivational enhancement strategies to support behavioral change

-Identify elements within a shared care plan

-Develop SMART goals that are patient centers

-Design patient centered action plans

-List factors leading to avoidable ED visits

-Recognize effective care coordination strategies to address avoidable ED visits


Session/Title Date
1 - Care Coordinators and Team-Based Care 9/5/2019
2 - Screening and Panel Management 9/12/2019
3 - Needs Assessment 9/19/2019
4 - Shared Care Plans 9/26/2019
5 - Self-Care Management Support 10/3/2019
6 - Cross Organizational Care Management 10/10/2019
Sign Up For This ECHO