Coordinating Person-Centered Care Transitions in Your Medical Neighborhood

Welcome to the Coordinating Person-Centered Care Transitions in Your Medical Neighborhood training. This learning module is intended to help practices develop a more streamlined and person-centered approach to care within the medical neighborhood in order to better align with the Quadruple Aim. Leaners will be oriented to what person-centered care transitions are and how some medical neighborhoods have implemented them utilizing existing models/best practices.


Learning Objectives

The following units are designed to:

  • Enhance knowledge of the varied components of a medical neighborhood and the key importance of the inclusion of social services providers in order to improve care transitions outcomes. (Driver: 1.5 Coordinated Care Deliver; Driver: 1.4 Practice as a Community Provider)
  • Provide practices with the skills to establish effective communication across their medical neighborhood as well as expand coordination to include social service providers and caregivers.
  • Promote the use of a person-centered approach in the context of care transitions. (Driver: 1.1 Patient and Family Engagement)
  • Gain knowledge and learn how to apply aspects of the essential elements of person-centered care. (Driver 1.2 Patient and Family Engagement; Driver 1.2: Team-based Relationships; 1.4 Practice as a Community Partner)
  • Assist practices in implement or integrating into an existing person-centered care transitions effort within their medical neighborhood. (Driver 1.6: Organized, Evidence-based Care, 1.4 Practice as a Community Partner)

You will also learn about the essential elements of person-centered care and how these provide the backbone for successful care transitions models. We will look at this in the context of your medical neighborhood, the importance of including social service providers to improve care transitions within your medical neighborhood. Lastly, we will look at how you and your practice can begin to implement (or align) with an already existing care transitions model or effort within your medical neighborhood.

Module Resources

Click here to access the resources and tools provided in the module.

Target Audience:

Practice and system leaders, providers, and staff enrolled in NNE-PTN.

Module Structure: 

This module is designed to allow you to work through the material at your own pace. Estimated time to complete will be 1.5 hours.  The module will consist of an introduction and 4 units and will contain the following elements:

  • Video lessons
  • Interactive presentations
  • Hyperlinks to readings, videos, web resources, and tools
  • Pre & post assessment

Duration & Fee:

  • Estimated Time to Complete: 1.5 hour

(note: the module is divided into short digestible units [5-20 mins] which can be completed in small increments)

  • Registration Fee: FREE for NNE-PTN members
  • CME Credits Offered: 1.5

Hardware/Software Requirements:

  • Computer with Internet connection
  • Current version of Chrome, Firefox or Safari browser. You must have javascript enabled.
  • The quiz tool within the online modules are not fully compatible with smartphones or tablets. In order to avoid issues, such as answers not being recorded, we recommend using a computer to complete the pre- and post-tests.

Assessment and Grading:

This learning module begins with a Pre-Test that will test your knowledge and allow you to gauge your baseline understanding of the topics to be covered. Your pre-test score will not count toward your overall grade. At the end of the module, there is a Post-Test that will determine your final grade. A comparison of your Pre-Test score and Post-Test score will help to assess how much knowledge you’ve gained. You will have two attempts to complete the Post-Test. Your score must be 75% or better in order to receive a certificate for CME credit.

Please complete the evaluation survey at the conclusion of the learning module.

To Obtain CME Credits:

  • Complete the entire learning module.
  • Complete the Pre-Test, Post Test, and Evaluation Survey at the end of the module.
  • You must earn a score of 75% or higher on the Post-Test in order to qualify for CME credits. You will have three attempts to complete the Post-Test.
  • After confirming that the entire learning module is complete and you have received a score of 75% or higher on the Post-Test, your certificate of completion will be generated and available for you for download.
  • A CME Documentation Form will be emailed.

Table of Contents:

  • Course Introduction (Orientation)
  • Test Your Knowledge (Pre-Test)
  • Unit 1:Introduction to Coordinating Person-Centered Care Transitions in Your Medical Neighborhood
  • Unit 2: Medical Neighborhood
  • Unit 3: Person-Centered Care
  • Unit 4: Person-Centered Care Transitions
  • Unit 5: Do It Yourself & Hybrid Models
  • Unit 6: Additional Resources and Tools
  • Course Wrap Up (Post-test and Evaluation Survey)


This activity has been planned and implemented in accordance with the Essentials and Standards of the Maine Medical Association Committee on Continuing Medical Education and Accreditation through the partnership ofMaine Medical Education Trust and Maine Quality Counts.  The Maine Medical Education Trust is accredited by the Maine Medical Association to provide CME activities for physicians.


The following planners, speakers and authors have indicated that they have no relationships with industry to disclose relative to the content of this activity:

Amy Belisle, MD
Medical Director
Maine Quality Counts

Joan Orr, MCHES, MBA
Program Director
Maine Quality Counts

Eleesa Marnagh, MPH
Lead Program Manager
Maine Quality Counts

Marguerite Corvini
Project Director
University of New Hampshire

Laura Davie
Director, Long Term Care and Aging
University of New Hampshire

Kate Crary
Program Manager
University of New Hampshire

Pieter Tryzelaar, M.Ed, MFA 
Manager of Education and Learning
Maine Quality Counts

Contact Information:

If you are having technical problems (video freezes or is unplayable, can’t print your certificate of completion, etc.) you can submit a Help Request ( to the QC Learning Lab Team. If you have questions related to CME credit and requirements (Pre and Post-test) or course content, please email

  • FREE
  • Course Certificate
Copyright 2016.  Maine Quality Counts.