Care Coordination Readiness Assessment Form Template

A qualification form for healthcare consultants that assesses an organization's care transitions, patient navigation, readmissions, data exchange, staffing, value-based contracts, budget, and timeline.

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Consultants who help hospitals, ACOs, and post-acute providers improve care coordination need to understand a prospect's starting point before proposing an engagement. A health system with mature navigation and strong data exchange needs different support than a practice with no formal transitions program. This assessment captures that baseline in one submission and doubles as a lead qualification step.

The form opens with the organization's name, type, and size, then asks about its main coordination challenge and current 30-day readmission rate. Operational questions follow on care transitions, patient navigation, interdisciplinary collaboration, care management platforms, EHR systems, health information exchange, risk stratification, value-based revenue, quality metrics, and staffing. The final section covers implementation timeline, the respondent's role in decisions, budget status, past consulting experience, goals, and contact details.

Answer options describe maturity levels in plain terms, so respondents can place their organization without pulling internal reports for every question. If the organization has worked with care coordination consultants before, a follow-up asks what worked and what could have been better. Personal contact details come near the end, after the respondent has already invested in the assessment.

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Frequently asked questions

Who should fill out this assessment?

It is meant for leaders at hospitals, health systems, ACOs, medical groups, post-acute facilities, home health agencies, and health plans. Roles such as population health directors, chief nursing officers, and care management leads usually have the context to answer accurately.

Does the form collect patient information?

No. Every question is about the organization, its processes, and its goals. Respondents should not include patient names or records in the open text fields, and you can add a short note saying so if you want to be explicit.

Does the assessment calculate a readiness score?

It does not compute a score automatically. The maturity-style options run from strongest to weakest, which makes it easy for your team to review a submission and judge readiness before a discovery call.

Why are contact details near the end?

Asking for name, title, email, and phone after the operational questions means respondents see the value of the assessment first. People who reach the end are usually more serious, which improves lead quality.

When does the previous consulting question appear?

Only respondents who say they have worked with care coordination consultants before see the follow-up about that experience. Everyone else moves straight on to their improvement goals.

Can I adapt it for a specific service line?

Yes. If you focus on readmission reduction or patient navigation, you can drop unrelated questions and add a few deeper ones on that topic. Keep the decision role, budget, and timeline questions so you can still qualify the lead.

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