Reference pages for each of the five Connected Care Protocols. Use these pages to prepare for patient visits and refresh your knowledge between encounters. For patient documentation, use the protocol tools provided by your clinic or the Connected Care team.
Protocol Templates
The Connected Care Protocol Tools are available as a Google Sheet (V3, updated April 2026). The sheet includes:
- Patient Intake Form
- CHW Encounter Form
- What Matters Conversation Protocol
- What Matters Advance Directive Protocol
- Medication Protocol
- Mentation Protocol
- Mobility Protocol
- Patient Exit Form
To request the current protocol tools: Contact the Connected Care team at [INSERT CONTACT EMAIL].
📋 Add callout (blue, info icon): “When you make a copy of the protocol sheet for your program, note the version number (currently V3) so you know when updates are available. The Connected Care team will notify programs when a new version is released.”
📋 Add callout (blue, info icon): “Protocol tools (intake form, encounter forms, exit form) are currently available as a Google Sheet. Contact the Connected Care team for the current version. Version: V3, Updated April 2026.”
📋 Add callout (yellow, warning icon): “All five protocols should be completed with every patient. Exception: if a patient has a dementia diagnosis, skip the memory screening portion of the Mentation protocol. If a patient has a depression, bipolar, or anxiety diagnosis, skip the mood screening portion.”
What Matters Conversation Protocol
The What Matters Conversation (WMC) is the foundation of Connected Care. It is typically the first protocol completed with a new patient. Its purpose is to understand what matters most to the patient — what they enjoy, what gets in the way, who they rely on, and what their goals are for working with a CHW.
When to use it
Complete the What Matters Conversation with every new Connected Care patient at or near the first home visit. It should also be revisited any time a patient’s situation changes significantly.
Key questions
- What is important to know about this patient? What matters most to them?
- What does the patient enjoy doing? (good days)
- What is currently getting in the way of doing what they enjoy? (bad days)
- Who does the patient rely on for help? What types of help do they need?
- As they think about the future, what is most important? What concerns do they have?
- What are the patient’s goals for working with a Connected Care CHW? (up to 3)
- Are there questions or concerns to share with the clinician?
Informal support and level of need
After the conversation, assess the patient’s level of support and need across five areas:
- Needs related to Food
- Needs related to Housing
- Needs related to Transportation
- Needs related to Companionship / Social Isolation
- Needs related to Independence, Safety, or Activities of Daily Living
Rate each area: None / Minimal / Some / A lot.
📋 Add callout (green, link icon): “Protocol tool: [Link to current WMC Google Sheet — request from Connected Care team]”
What Matters Advance Directive Protocol
The What Matters Advance Directive (WM-AD) protocol supports patients to understand, complete, update, and document their advance directive status. It is closely connected to the Advanced Directives training module.
When to use it
Complete with every patient. Begin by checking the patient’s advance directive status in the EMR, then use this protocol to move the patient toward having a current, signed advance directive on file.
Advance directive status — document one of the following
- Patient completed a new Advance Directive
- Patient updated existing Advance Directive
- Patient is considering completing an Advance Directive
- Patient declined to complete an Advance Directive
Key resources for this protocol
- Advanced Directives Training Module — complete this module before using this protocol
- Five Wishes — an alternative advance care planning tool
- Prepare for Your Care — step-by-step tools for patients and families
- The Conversation Project — resources and guides for families
📋 Add callout (green, link icon): “Protocol tool: [Link to current WM-AD Google Sheet — request from Connected Care team]”
Medication Protocol
The Medication protocol supports patients to safely manage their medications at home. It involves reviewing all medications in the home, identifying discrepancies with the EMR medication list, and flagging issues that require clinical review.
When to use it
Complete with every patient. A full medication review typically takes place during or shortly after the first home visit.
What the CHW does
Issues that require clinical review (flag for PCP):
- Identified discrepancies with the medication list on file in the EMR
- Patient is not taking all medications as prescribed
- Patient has concerns about their medications
- Patient has trouble refilling medications
- Patient has trouble paying for medications
- Patient has medicines prescribed by more than one prescriber
- Patient has prescriptions filled at more than one pharmacy
Issues the CHW can address directly:
- Provided resources to safely dispose of medications
- Requested easy-open bottles
- Provided a system for organizing medications
Key resources for this protocol
- Med Project mail-back supplies — Call (844) 482-5322
📋 Add callout (green, link icon): “Protocol tool: [Link to current Medication Protocol Google Sheet — request from Connected Care team]”
Mentation Protocol
The Mentation protocol screens patients for memory and cognitive concerns as well as mood concerns including depression, loneliness, and suicide risk. It uses validated screening tools (MoCA or SLUMS for cognition) and structured questions for mood.
When to use it
Complete with every patient — with the exceptions noted above for patients with existing dementia or mood disorder diagnoses.
Memory screening
The CHW completes either the MoCA or SLUMS cognitive screening and records the score. If the patient has an existing dementia diagnosis, skip the memory screening portion.
Issues requiring clinical review:
- Patient shared concerns about their memory
- Family members or loved ones have concerns about patient’s memory
- Confusion or memory loss makes normal activities difficult
- Confusion or memory loss appears to be changing or worsening
Mood screening
Issues requiring clinical review:
- Patient has noticed recent changes in mood
- Patient has been feeling lonely
- Patient has been feeling sad or blue
- Patient has lost interest in things they used to enjoy
- Patient shared recent, current, or planned thoughts of suicide
📋 Add callout (red, urgent icon): “If a patient shares current or planned thoughts of suicide, do not leave the visit without following your clinic’s crisis protocol. Call or text 988 (Suicide & Crisis Lifeline) for immediate support. See the Suicide resources in the Resource Library.”
Key resources for this protocol
- MoCA certification — optional but recommended
- 988 Suicide & Crisis Lifeline — call or text 988
📋 Add callout (green, link icon): “Protocol tool: [Link to current Mentation Protocol Google Sheet — request from Connected Care team]”
Mobility Protocol
The Mobility protocol assesses and addresses fall risk in the home. It includes a home safety review, footwear assessment, mobility aid check, the STEADI fall risk assessment, and the development of an exercise plan.
When to use it
Complete with every patient. The home safety and STEADI assessment are ideally done during the first home visit.
What the CHW does
- Reviews the home for fall risks
- Reviews the patient’s footwear for safety
- Reviews mobility aids (walker, cane, etc.)
- Administers the STEADI Fall Risk Assessment — alert PCP if score >4
- Removes or addresses fall hazards where possible
- Makes a plan to address hazards that cannot be easily resolved
- Helps the patient develop an Exercise Plan (strength and balance, at least 3x per week)
Issues requiring clinical review:
- STEADI score >4
- Open sores on feet or legs
- Pain, inflammation, tingling, or numbness in feet or legs
- Foot care / hygiene needs
- Gait concerns or changes
Key resources for this protocol
- Silver Sneakers — exercise program, covered by Medicare
- Sit and Be Fit — online video classes
- Senior centers often have durable medical equipment to loan (walkers, canes, grab bars, wheelchairs)
Grab bar recommendations:
- Screw-in grab bar (~$25 on Amazon) — ADA approved, good reviews
- Over-tub grab bar (Home Depot) — supports up to 250 lbs, no construction required
- Home Depot professional grab bar installation: $100–$150
- Note: suction grab bars are less reliable and should not be installed on textured tile or over grout lines
- Screw-in grab bar (~$25 on Amazon) — ADA approved, good reviews
- Over-tub grab bar (Home Depot) — supports up to 250 lbs, no construction required
- Home Depot professional grab bar installation: $100–$150
- Note: suction grab bars are less reliable and should not be installed on textured tile or over grout lines
📋 Add callout (green, link icon): “Protocol tool: [Link to current Mobility Protocol Google Sheet — request from Connected Care team]”
Patient Intake Form
📋 Note: The intake form captures patient demographics, insurance, health status, emergency visit history, advance directive status, and the primary reason for referral (which protocol). It is completed at the start of a patient’s enrollment in Connected Care.
📋 Add callout (green, link icon): “Protocol tool: [Link to current Intake Form Google Sheet — Version V3, request from Connected Care team]”
Patient Exit Form
📋 Note: The exit form captures the reason for leaving Connected Care, the patient’s current level of support and unmet needs at exit (for comparison to intake), and program end date. It is completed when a patient leaves the program for any reason.
Exit reasons include: protocols complete and priority needs addressed / no contact >30 days / withdrew from program / transferred care / moved to higher level of care (assisted living, hospice) / death / other.
📋 Add callout (green, link icon): “Protocol tool: [Link to current Exit Form Google Sheet — Version V3, request from Connected Care team]”
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