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Care Coordination Tool

Welcome to your centralized hub for the Care Coordination Tool! Throughout this site, you will find information about the CCT, news and updates, and materials designed to help you learn how to use the CCT. Whether you are an experienced or first-time user, we hope you will explore all that is available and, of course, let us know if we can help in any way!

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What is the Care Coordination Tool

The Care Coordination Tool is a shared, web-based application that allows providers participating in the Patient Centered Medical Home (PCMH) and Tennessee Health Link programs to identify gaps in care linked to quality measures and coordinate and track the closure of those gaps.

The CCT is based on a rich data set that supports care coordination and offers providers information and benefits like:

Immediate access to more reliable and timely quality measures. The CCT calculates and displays all of the state approved PCMH and THL HEDIS Quality Measures, including diabetes screening, well-child visits, childhood immunizations, and high blood pressure monitoring.

Ability to view the count of members with care gaps open, and the total number of members that are up-to-date on care milestones. This helps those needing care coordination based on care gaps and missed services identified from the PCMH and THL HEDIS quality measures.

Member panel information such as name, address, phone numbers, and more support outreach efforts as providers seek to connect with new and established members.

Admission, discharge, or transfer (ADT) data from hospitals and/or emergency rooms.

Immunization data reported by immunizing providers to the Tennessee Department of Health (TDH) for members under the age of 2 years, or aged 9-13 years.

Claims-based clinical data that outfits providers with information like risk score, medication history, diagnosis history, and visits—information that in tandem with knowledge regarding a member’s open gaps in care enables providers to establish a more robust understanding of a member’s overall medical history.

  • Real time updates on drug contraindications, drug disease interactions, and drug allergy reactions
  • Easy searching and segmenting of MTM members through a range of filters including chronic conditions, PCP, and zip code. As an added feature, alerts can be set for members with chronic disease, comorbidities and high-risk levels.
  • Intuitive CMR/TMR that guides you through collecting patient information, assessing prescriptions, developing a list of medication-related problems, and creating a medication action plan.

Care alerts that provide information on new and enrolled members, particularly high-risk members.

Learning and Training

Learn how to navigate the tool using some of the training materials available in learning library. Materials include:

  • Short, quick-reference-guides that walk you through some of the more common tasks or actions performed in the CCT
  • High-level, process-oriented modules that outline how to use the CCT in support of coordination-related processes like pre-visit planning, member outreach, and quality measure management
  • Recorded webinars detailing the “clicks and tricks” of how to navigate in the tool and access certain pieces of information
  • Programmatic information like PCMH and THL annual program guides and coding reference guides

Contact Us

Have questions about the Patient Centered Medical Home (PCMH) and Tennessee Health Link programs? What about the Care Coordination Tool itself? Want to provide some feedback—we love feedback!—or report an issue?

Visit the Contact Us page to submit your questions, comments, and/or feedback.