"

Toolkit

Implementing the complex care core competencies

A toolkit to guide education and training.

Building the complex care field Education & training Workforce development

Scroll to the Top

Overview

This toolkit is intended for anyone who is interested in implementing complex care education in their institution, or in training a team or individual to deliver complex care.

In this toolkit, “complex care education” will refer to training in formal educational institutions (e.g., universities) and “complex care training” will refer to training in practice sites (e.g., complex care teams).

This toolkit was designed to help educators and trainers:

  • learn more about the principles of teaching and training complex care,
  • identify gaps or weak areas in your training, education, or competency assessment program by comparing your plan against the complex care core competencies, and
  • identify and integrate the resources, case studies, and discussion questions needed to fill those gaps.

The toolkit is split into 5 sections:

  • Section 1 provides an overview of complex care and its principles.
  • Section 2 outlines key considerations for educators developing complex care education in a higher education setting.
  • Section 3 outlines key considerations for managers developing a complex care training program for current practitioners.
  • Section 4 lists each of the competencies. Under each competency is a set of more specific sub-competencies and resources that can be used to teach that competency.
  • Section 5 includes a list of case studies that can be used as the basis for role plays or discussions. It also includes example questions organized by domain to prompt discussion.

How to use this toolkit

  1. Review the principles of complex care in Section 1. 
  2. Review key considerations for education or training individuals in complex care.
    • If you are developing complex care education in a higher education setting, reference Section 2. 
    • If you are developing complex care training for current practitioners, reference Section 3. 
  3. Compare your plan to the complex care core competencies in Section 4 and identify gaps or weak areas in your training, education, or competency assessment.
  4. Use the resources, case studies, and discussion questions in Section 5 to fill gaps.

Section 1- Overview of complex care and its principles

This section defines the field of complex care, its principles, and the core competencies for frontline complex care providers.

Section 2 – Key considerations for educators developing complex care education in a higher education setting

This section provides an overview of interprofessional education and complex care, describes methods to make the case for complex care in educational settings, strategies to teach complex care to students and foster community practice/education partnerships, and recommendations for assessing learning.

Section 3 –  Key considerations for managers developing a complex care training program for current practitioners.

This section provides recommendations for organizing training in a practice setting, reviews best practices for hiring and training for attitudes, and discusses how to train and evaluate complex care staff.

Section 4 –  Competencies and resources

This section includes curated resources for each complex care core competency. Expand each domain below to find the competencies and corresponding resources.

Domain: Human complexity and context

Description: Delivering effective complex care requires an empathetic understanding that the human experience is complicated and that poor health and inadequate living conditions have multiple causes, including an interplay of physical and behavioral health, structural and social conditions, racism, stigma, and bias.

Context: These competencies constitute an orientation that complex care team members apply to interactions with individuals, teams, and systems. Using that orientation to inquire about, listen for, and adapt to an individual’s context is especially important in complex care because the intersection of health and social needs, exposure to trauma, and stigma evolve throughout the lifespan. Complex care team members understand these complexities and support individuals in reaching their goals within their own context. Additionally, many challenges and inequities faced by individuals are ingrained in governmental, cultural, and social systems and thus environment and context are not always immediately modifiable. Complex care team members aim to balance seeking to change an individual’s environment and supporting them within it.

Competency 1. Obtain and apply foundational knowledge in:

Physical and behavioral health as relevant to the discipline and context

  • Describe basic concepts relevant to human growth and development, disability, disease states, and chronic disease management.
  • Understand basic concepts about substances, substance use disorders, and substance-related health conditions.
  • Demonstrate basic knowledge of the biological, social, affective, and cognitive bases of behavior.

Resources:

Social drivers of health

  • Understand the health and healthcare utilization impact of social deprivation and unmet needs.
  • Analyze the macro (e.g., housing policy) and mezzo (e.g., social class, gender, race, ethnicity, place of birth, disability, physical environments) determinants of individuals’ and populations’ health.

Resources:

Interplay and compounding effects of multiple health and social needs

  • Consider the interplay and compounding effects of multiple health and social needs (comorbidity).

Resources:

  • Co-occurring disorders and other health conditions – A lesson plan from the Substance Abuse and Mental Health Services Administration (SAMHSA) about co-occurring disorders and other health conditions that can occur in people who are in medication-assisted treatment (MAT) for substance use disorders

Frameworks used in the care of people with complex needs such as recovery model, strengths-based practice, resilience, and person-in-environment

  • Identify and apply frameworks used to understand and provide care for complex needs.

Resources:

Trauma-informed care, including the impact of adverse childhood experiences, historical trauma, and structural oppression (e.g., racism, sexism, etc.)

  • Define the core concepts of adverse childhood experiences, trauma, toxic stress response, trauma-informed and trauma-specific care, and retraumatization.
  • Promote environments of healing and recovery in the context of historical and ongoing trauma to avoid further harm.

Resources:

Philosophy and practice of harm reduction

  • Define and apply the core principles and practices of harm reduction.

Resources:

  • Harm reduction training – A three-part powerpoint presentation from Hill Country Community Clinic helps you train others on harm reduction philosophy and practices. The first two parts are 1.5 hours minimum and the third part is 1 hour minimum. The training is optimally provided in-person
  • Insite – not just injecting, but connecting – This video from Drugreporter provides an example of harm reduction work in action
  • Harm reduction education on demand – A self-paced course from Harm Reduction Coalition provides a deeper perspective into harm reduction principles and practices

Models and techniques of behavior change

  • Identify and apply methods of engagement and care delivery that promote behavior change to achieve the individual’s goals.
  • Examine the challenges of and opportunities for human behavior change.

Resources:

Competency 2. Evaluate, respect, and incorporate the diversity of values, strengths, cultures, and personal preferences of individuals, families, and colleagues.

  • Assume a stance of cultural humility to understand the needs of individuals.
  • Apply cultural intelligence skills and strengths-based practice to support the needs of individuals with diverse backgrounds.

Resources:

  • Cross-cultural issues in integrated care – A powerpoint presentation from SAMHSA on communicating about health disparities, the importance of cross-cultural education, and practical methods for improving cultural competence
  • Improving cultural competency for behavioral health professions – Training modules from the US Department of Health and Human Services (HHS) that help behavioral health professionals increase their cultural and linguistic competency
  • Cultural competency/humility – General and specialty trainings from Colorado School of Public Health about cultural humility, cultural competency, and cultural diversity
  • Cultural competence – A curricula enhancement module series from the National Center for Cultural Competence that helps faculty incorporate key cultural and linguistic competence content areas into existing curricula, offers resources for each content area, and provides instructional and self-discovery strategies.
  • A practical guide to implementing the national CLAS standards: For racial, ethnic and linguistic minorities, people with disabilities and sexual and gender minorities – A practical guide from the Centers for Medicare & Medicaid Services on implementing the National CLAS Standards and improving health equity.
  • LGBTQ health clinical training using the eQuality toolkit – An online primer training from the University of Louisville School of Medicine on addressing gaps in patient care for those who identify as a part of the LGBTQ community

Competency 3. Apply tenacity, ingenuity, and divergent thinking to actively work to eliminate complex and deeply ingrained individual- and community-level health disparities.

  • Demonstrate the discipline, determination, and resilience necessary to achieve goals in the face of setbacks, obstacles, or challenging environments.
  • Describe strategies to solve difficult problems in original, clever, and inventive ways.

Resources:

  • Uncertainty as the norm – A video from the National Center on how leaders think about the future of complex care
  • Adaptability and flexibility – A lesson plan and presentation from Health Workforce Initiative (HWI) on the importance of adaptability and flexibility.
Domain: Personal and professional Commitment and ethics

Description: Complex care team members are deeply and ethically committed to improving the lives of individuals experiencing vulnerability, believe in transformative change at the individual and system levels, engage in continuous learning and self-improvement, and serve as examples of hope and ingenuity.

Context: The work of complex care can be both deeply challenging and rewarding. It requires significant self-reflection to identify and overcome ingrained biases. Routine personal and team check-ins can help sustain a commitment to working with individuals who have complex needs despite the systemic barriers and challenges individuals are facing.

Competency 1. Develop, implement, and evaluate innovative approaches to supporting individuals and families.

  • Understand traditional approaches to supporting individuals and families, including their limitations and challenges.
  • Pilot and test new and creative approaches to maximize the effectiveness of care and support for individuals.
  • Solicit feedback from individuals receiving care and colleagues regarding effective methods of engagement, care planning, and care delivery.

Resources:

Competency 2. Champion resilience and a strengths-based perspective for individuals, families, communities, teams, and systems.

  • Support individuals in adapting to or challenging change and overcoming adversity.
  • Identify and support individuals in identifying their own strengths, resourcefulness, and resilience in the face of adversity.
  • Communicate specific examples of individuals’ strengths, resourcefulness, and resiliency to themselves, their families, and their other practitioners.
  • Use techniques to build on individuals and families’ strengths.

Resources:

Competency 3. Identify and develop strategies of self-care to address moral injury and foster joy in work.

  • Identify individual strategies to protect and nurture one’s own well-being.
  • Identify team-based strategies to sustain and promote team member well-being.

Resources:

Competency 4. Employ the skills and perspective of self-reflection, cultural humility, anti-racism, and unconditional positive regard to mitigate personal and systemic biases and stigmas and to repair historical and personal harms.

  • Cultivate a practice of active self-reflection.
  • Exhibit a non-judgmental openness to and celebration of personal and cultural identities.
  • Demonstrate unconditional acceptance of individuals by setting aside personal opinions and biases.
  • Cultivate an understanding of structural racism and implicit bias and the strategies to dismantle racism.
  • Implement strategies to develop in self and others the skills of cultural intelligence.

Resources:

Competency 5. Understand and maintain appropriate professional boundaries and limitations within relationship-delivered care.

  • Understand the essential elements of professional relationships and the dangers associated with boundary crossing.
  • Identify and apply the boundaries of professional ability and scope of practice.

Resources:

Domain: Person centered, relationship-power care

Description: Complex care team members value the autonomy and agency of individuals and families and recognize the importance of authentic healing relationships that support efforts to improve health and well-being.

Context: Complex care team members appreciate both the autonomy of the individual (including their right to determine their goals and care plan) and the importance of mutual, respectful, therapeutic relationships between individual and care team to support the individual in achieving those goals. The team members support the individual’s capacity and self-direction through the provision of discipline- and profession-specific medical and/or social expertise and access to resources.

Competency 1. Build authentic healing relationships that prioritize self-determination and encourage bi-directional feedback to inform goal setting and care delivery.

  • Apply relationship-building skills incorporating safety, genuineness, and continuity to build a trusting partnership with the individual and their family.
  • Demonstrate empathy and compassion in relationship-building and care delivery.
  • Engage individuals in the practice of shared decision-making.
  • Partner with individuals and families to provide and receive appropriate observations, reactions, and preferences to encourage and improve cooperative care.

Resources:

Competency 2. Create and maintain relevant shared care plans that reflect the goals and priorities of the individual and family.

  • Foster mutual respect with the individual receiving care.
  • Demonstrate an understanding of evidence-based assessment and care planning techniques to coordinate comprehensive care plans.
  • Implement individual- and family-centered care planning.
  • Understand processes for shared care planning across organizations.
  • Examine how population characteristics and disparities and individual preferences factor into care planning.

Resources:

  • Patient- and family-centered care – An article from the Institute for Patient and Family Centered Care on the planning, delivery, and evaluation of healthcare that is grounded in mutually beneficial partnerships among healthcare practitioners, patients, and families

Competency 3. Partner with individuals and families to anticipate and address challenges in implementing care plans, including navigating complex systems and non-linear pathways.

  • Demonstrate an understanding of how to tenaciously navigate a complex system.
  • Analyze individual and structural barriers to care, including system gaps.
  • Determine which prevention practices are most appropriate to implement based on analysis of barriers to care, risk assessment, and individual preferences.
  • Share knowledge with individuals about their conditions and options to receive care to inform decision-making.

Resources:

Competency 4. Employ established techniques to meet people where they are, create safety, and explore behavior change.

  • Identify appropriate evidence-based models of engagement and care planning based on individual characteristics, conditions, and preferences.
  • Assess individuals’ readiness for behavior change with respect and non-judgement.
  • Demonstrate respect for an individual’s values, needs, emotions, and readiness for behavior change.
  • Support individuals in identifying opportunities for behavior change.

Resources:

Competency 5. Coordinate access to social and medical care and supports with continuity.

  • Identify resources, resource platforms, and strategic partners to meet an individual’s needs.
  • Differentiate among care support models to appropriately refer individuals to other levels or types of care.
  • Apply customized methods of communicating and partnering with other practitioners based on individual characteristics, conditions, and preferences to enable optimal care coordination and transition.
  • Identify methods of engaging after a referral to appropriately sustain communication and care with the individual.

Resources:

Competency 6. Cultivate individuals’ resilience, ability, and self-efficacy in high-stakes moments and their ability to navigate setbacks, barriers, and complex systems.

  • Identify the appropriate level of care to support an individual and their self-determination.
  • Provide individuals with feedback on their strengths and how to use them.
  • Identify opportunities for engagement with individuals during escalating situations.
  • Identify appropriate teaching methods during challenges to build capacity for similar future challenges.

Resources:

Domain: Integrated and team collaboration

Description: Complex care relies on highly functioning, collaborative care teams that coordinate across multiple settings and in partnership with individuals and families.

Context: A complex care team is most successful when its members from diverse disciplines, practices, professions, and perspectives are collaborating to support the individual in reaching their goals. Interprofessional teams support individuals with numerous, diverse, and interrelated needs by effectively integrating social care and healthcare delivery. An interprofessional complex care team also coordinates with practitioners and partners from other departments within their organization and with other organizations. The role of each team member and partner is well-defined but may also depend on the context, needs, and goals of the individual receiving care and the specialty of the team member. Complex care team members have more access to and opportunity for decision-making, leadership opportunities, and changemaking through collective leadership. Collective leadership posits that everyone on a team can and should lead. The collective leadership philosophy is based on the principles of trust, shared power, transparent and effective communication, accountability, and shared learning.

Competency 1. Understand and respect the distinct role of each care team member, including the individual and family.

  • Identify the role, purpose, and function of each team member.
  • Demonstrate respect for team members’ expertise and experience.
  • Describe basic principles of family dynamics and family support.

Resources:

Competency 2. Develop mutual trust, support, and shared identity among care team members.

  • Identify components of effective inter-professional team formation and performance.
  • Identify team-building and communication strategies to foster alignment on vision/values/mission, strategic priorities, goals, boundaries, and measures of success.
  • Nurture a professional identity appropriate to role and setting.
  • Demonstrate an appreciation of the individual’s voice in the setting of the team’s work.
  • Foster an environment in which all team members are able to challenge team decisions and structures.

Resources:

Competency 3. Communicate clearly and directly, orally and in writing, to coordinate activities and collaborate with the individual, family, and service partners.

  • Assess individuals’ capacity and preference to engage with diverse forms of information.
  • Communicate orally and in writing at an appropriate complexity level for the audience.
  • Identify appropriate and respectful methods of integrating technology.
  • Demonstrate clear and respectful written documentation to facilitate care coordination and continuity of care.

Resources:

Competency 4. Employ techniques of conflict resolution, bi-directional feedback, and active listening to build, sustain, and repair relationships with colleagues.

  • Identify opportunities for engagement with team members during escalating situations.
  • Facilitate the prevention and resolution of conflict while preserving working relationships.
  • Partner with colleagues to communicate appropriate observations, reactions, and preferences to encourage and improve cooperative care.
  • Apply skills of active listening including focusing completely on the speaker, understanding their message, comprehending the information, and responding thoughtfully to improve mutual understanding.

Resources:

Competency 5. Contribute to collaborative decision making and collective leadership.

  • Use person-centered collaborative care with interdisciplinary teams.
  • Apply shared decision-making principles related to interdisciplinary teams to meet shared goals.
  • Foster an environment of trust, mutual respect, and humility to facilitate collective leadership.
  • Contribute skills and perspective to inform team goals and success.

Resources:

Domain: Diverse information and management

Description: Complex care team members collect and use quantitative and qualitative information, including from the individual and their family, to identify clients, assess needs, adapt best practices, and continuously improve the delivery of care and supports. The term “information” includes both quantitative and qualitative data, including stories that derive from a variety of sources.

Context: As complex care is in a formative stage, the field needs to develop knowledge through research, quality improvement, and evaluation. Complex care also should look to adapt best practices from more frequently studied interventions for populations without complex needs. At the individual level, complex care promotes the integration of whole-person information. At the systems level, integrating cross-sector information allows team members to identify individuals who need the most support and to collaborate to address their specific needs, maximizing impact and improving outcomes across systems.

Competency 1. Understand best practices in gathering, documenting, and sharing individual-level information, and the impact of bias inherent in those processes on the delivery of care.

  • Understand the impact of unconscious bias on data collection and distribution.
  • Demonstrate methods of meaningful, trauma-informed, and person-centered data collection, documenting, and sharing.
    • Demonstrate ability to respectfully educate individuals on their rights and the risks of sharing information.
    • Demonstrate ability to elicit individual preference for how and when information is shared.
  • Identify ethical, legal, and regulatory requirements of data collection and storage to ensure compliance and minimize impact on individuals.

Resources:

Competency 2. Assess the root cause of individual health needs and population disparities to inform care, programmatic, and systems-level decisions.

  • Analyze the complex systems surrounding individuals to identify needs.
  • Analyze the complex systems surrounding populations to identify reasons for health disparities.
  • Apply knowledge of key needs and reasons for health disparities to inform care delivery and programmatic and systems-level decisions.
  • Demonstrate ability to define a root cause and conduct a root cause analysis.

Resources:

Competency 3. Carefully evaluate and implement the current available evidence base to inform care appropriate for each individual’s context, as well as programmatic interventions and systems-level policy.

  • Demonstrate knowledge of current research and promising practices related to methods of engagement, care planning, and care delivery.
  • Evaluate the value and limitations of evidence-based practices to care delivery across all environments and contexts to provide optimal care.
  • Use evidence-based and promising practices to inform individual practice.

Resources:

Competency 4. Continuously collect, use, and evaluate information to drive resource allocation, improve the quality of care, and improve team member experiences in delivering that care.

  • Identify core principles and practices of quality improvement science.
  • Analyze information to inform tactical decision making.

Resources:

Competency 5. Disseminate lessons, resources, and best practices to individuals, colleagues, community partners, policymakers, and others in the field.

  • Identify methods of sharing available knowledge, emerging best practices, evidence, and research in an accessible manner with various stakeholders.
  • Identify methods of interpreting findings and information for various audiences and uses.

Resources:

  • Written communication skills (presentation) – A lesson plan and presentation from HWI to help teach the importance of effective written communication in the healthcare setting
  • Audience adaptation – An article from the University of Pittsburgh’s Department of Communications on how to identify an audience and adapt materials to their interest, level of understanding, attitudes and beliefs
Domain: Systems complexity and context

Description: Individuals with complex needs interact with multiple — often incongruous — systems that can each present barriers to improving health and well-being. The complex care workforce analyzes individual problems from a systems perspective and advocates for systems reform and policies that foster whole-person health.

Context: Complex care team members understand that individuals’ opportunities for health and well-being are determined in part by the interplay of multiple actors (e.g., political, community, environment) within systems including healthcare, human services, and public health. Care team members operate within existing systems while also working to improve those systems through collaboration, coalitions, and advocacy. Team members support individuals in creatively navigating and problem-solving within these systems. Team members often become liaisons between their organization’s policies and systems and the individuals with whom they are working. Cross-system operational and cultural literacy allows team members to collaborate and coordinate services to better meet the diversity of health and social needs.

Competency 1. Understand essential elements of healthcare, human services, and public health sectors and strategies for sharing information and integrating service delivery across sectors.

  • Develop understanding of relevant health and social care systems and their associated barriers and challenges.
  • Analyze standards of practice across industries to apply professional behavior and effective communication practices.
  • Demonstrate ability to translate and transmit information across sectors.
  • Cultivate relationships and knowledge to build collaborative care efforts.

Resources:

Competency 2. Understand basic elements of the local, state, and federal civic processes.

  • Identify the stakeholders, roles, structures, and processes of local, state, and federal government entities.
  • Identify the processes through which civic entities affect care delivery and the environment in which it exists.

Resources:

Competency 3. Collaborate and organize with members of the health and social sectors and with community members to build and maintain coalitions and collaborative structures.

  • Identify strategies to engage, develop, sustain, and grow community relationships.
  • Develop strategies for communication, collaboration, and relationship building among interprofessional teams to maximize team effectiveness and challenge traditional professional boundaries and structures.
  • Collaborate with community partners in identifying the source of challenges, setting goals, developing an action plan, considering possible outcomes, and implementing the action plan.

Resources:

Competency 4. Use collective power, privilege, and access to question the status quo and advocate for policy change.

  • Understand and leverage self and team positionality related to power, privilege, and oppression and how that positionality influences work with the community and with the targets of advocacy (e.g., decision-makers).
  • Identify and question long-standing or normed policies and practices in programs, organizations, and systems that are not benefiting individuals with complex needs.
  • Identify methods of influencing decision-makers to implement lasting change.

Resources:

Competency 5. Inform others’ understanding of challenges and potential systems-level solutions by synthesizing personal narratives and aggregating information.

  • Consult with communities affected by specific challenges to understand their views and experiences, with attention to economic, social, and cultural perspectives.
  • Collaborate with individuals to prepare written and multimedia materials that explain how systems-level and environmental factors cause or exacerbate the harm they experience.
  • Authentically center and amplify community voices to educate and influence decision makers, legislators, and policymakers.
  • Identify methods of communicating stories and other information to influence a targeted audience.

Resources:

  • Who tells the story? – A guide from Kate Marple on strategies, considerations, and tools for storytelling
  • Storytelling framework – A framework from the San Mateo County Office of Diversity and Equity with strategies, considerations, and tools for storytelling
  • Storytelling template – A template from the CDC with strategies, considerations, and tools for storytelling

Competency 6. Recognize and adapt to the current processes and structures of organizations, systems, and policies while seeking to effect positive and aspirational change.

  • Analyze how organizational hierarchy, policies and procedures, and personnel resources both contribute to and hinder the organization achieving its mission and vision
  • Use leadership, professionalism, and emotional intelligence to assess interpersonal, organizational, and system-level dynamics and select the appropriate approach to effect positive change
  • Advocate internally for organizational policies, processes, and structures that reduce harm and increase the quality of care delivery and team member wellness

Resources:

  • Escape fire – A film on the powerful forces that maintain the status quo
  • Workplace health promotion model – An overview from the CDC helps encourage workplace health promotion
  • Emotional intelligence lesson plan and presentation – A lesson plan and presentation from HWI on emotional intelligence, assessments of emotional intelligence, and strategies to improve emotional intelligence

Section 5 – Case studies

This section provides educators and trainers with a series of role-plays and scenarios to use as simulations during training for staff and students to help learners apply the knowledge, skills, and attitudes described in the core competencies to real situations.