Resources and Improvement Strategies


Patient Support Individualized Assessment Self Management Education Goal Setting Problem-Solving Skills Emotional Health Patient Involvement Social Support Links to Community Resources Organizational Support Continuity of Care Coordination of Referrals Ongoing Quality Improvement System for Documentation Patient Input Integration into Primary Care Patient Care Team Staff Education and Training General Resources The Diabetes Initiative Institute for Healthcare Improvement Institute for Family-Centered Care Health Disparities Collaboratives Improving Chronic Illness Care (ICIC) Institute for Healthcare Communication National Center for Cultural Competence New Health Partnerships The Commonwealth Fund

Patient Support

Individualized Assessment
Self Management Education
Goal Setting
Problem-Solving Skills
Emotional Health
Patient Involvement
Social Support
Links to Community Resources

Organizational Support

Continuity of Care
Coordination of Referrals
Ongoing Quality Improvement
System for Documentation
Patient Input
Integration into Primary Care
Patient Care Team
Staff Education and Training

General Resources

The Diabetes Initiative

Institute for Healthcare Improvement

Institute for Family-Centered Care

Health Disparities Collaboratives

Improving Chronic Illness Care (ICIC)

Institute for Healthcare Communication

National Center for Cultural Competence

New Health Partnerships

The Commonwealth Fund

Patient Support

1. Individualized Assessment of Patient’s Self management Educational Needs
Improvement Strategies	Resources and Tools
• Standardize intake questions • Assess patient behaviors and readiness to change • Determine patients preferred learning style and language preference • Incorporate assessment of health literacy and numeracy	Tools from the Diabetes Initiative website Behavioral Health Assessment Tool Self Efficacy Assessment Tool Are You Ready? Brochure Stages of Change Questions CMI (Comprehensive Motivational Interventions) Interview Guide © Tell Us How You’ve Been Doing Behavioral Assessment Summary of Diabetes Self-Care Activities (SDSCA) Assessment Health Risk Assessment How’s Your Health Patient Activation Measure (PAM) Licensing information Hibbard article on the development of the PAM Health Literacy: (English and Spanish) The Newest Vital Sign (NVS) American Medical Association kit—Health literacy and patient safety: Help patients understand Transforming the Face of Health Professions Through Cultural & Linguistic Competence Education: The Role of the HRSA Centers of Excellence
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2. Patient Self management Education
Improvement Strategies	Resources and Tools
• Develop key messages and terminology that will be used by all team members to reinforce key concepts • Offer different formats and venues for patient education and self management services • Use educational processes and materials that are culturally relevant and literacy/language appropriate • Use teach-back techniques • Develop resources for timely translation services	Tools from the California HealthCare Foundation Helping Patients Manage Their Chronic Conditions Motivating Change: Innovative Approaches to Patient Self-Management Telephone based support (AHRQ) Conversation Maps™ (Merck) Chronic Disease Self Management Program Language appropriate materials http://www.healthtranslations.com/ http://ndep.nih.gov Family Curricula Diabetes and the Family Curriculum Tools from the Diabetes Initiative You Can Do It Poster Are You Ready? Balance Your Plate Booklet Are You Ready? Chose to Move Booklet Are You Ready? Kick the Habit Self Management Goal Setting Trifold La Clinica TTM brochures Self Assessment and Action Planning Guides Live Your Life! Control Your Diabetes Translation services National Council on Interpreting in Healthcare
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3. Goal Setting
Improvement Strategies	Resources and Tools
• Provide education and training on collaborative goal setting to all team members (see #8 in organization supports section) • Participate in collaborative goal setting with all patients • Document goals so that all team members can reinforce • Establish follow up and monitoring procedures	Goal Setting Resources from the Diabetes Initiative Tools from the Diabetes Initiative: (routine documentation/ tracking of goals) Goal Setting Contact Sheet Goal Setting Form Self Management Goal Tracking Sheet Type II Diabetes Standing Orders Self Management Call Back Cards (for use in goal setting with patients) Goal Setting Assessment Tool Self Management Goal Form Goal Setting Form and Tips Self Management Goal Follow up Form Weekly Action Plan Form Steps to an Action Plan TTM Brochures (on checking blood sugar, exercise, meal planning and taking medicine) Goal Follow Up Form Becoming An Active Self Manager Chapter 2 in Living a Healthy Life with Chronic Condition, 3rd Ed. Lorig, et al. Bull Publishing Physician tip sheet for self-management support
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4. Problem-Solving Skills
Improvement Strategies	Resources and Tools
• Train all members of the team in the same problem solving approach (see #8 in organization supports section) • Incorporate teaching problem solving processes to patients as a self management skill • Use problem solving techniques with patients in goal follow up	Tools from New Health Partnerships Chronic Disease Self Management Program Becoming An Active Self Manager Chapter 2 in Living a Healthy Life with Chronic Condition, 3rd Ed. Lorig, et al. Bull Publishing Literature Hill-Briggs, F. & Gemmell, L. Problem solving in diabetes self-management and control. The Diabetes Educator 2007;33;1032.
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5. Emotional Health
Improvement Strategies	Resources and Tools
• Make depression/ emotional health screening a routine part of chronic illness care • Standardize screening and referral protocols • Ensure systems for feedback on referrals so all providers are reinforcing the same goals • Incorporate teaching healthy coping skills into self management education	Tools from the Diabetes Initiative MacArthur Foundation Depression site, PHQ9 Recovery Model Healthy Coping in Diabetes: A Guide for Program Development and Implementation
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6. Patient Involvement
Improvement Strategies	Resources and Tools
• At each visit, describe/ reinforce the patient’s role in their self management and your role in supporting them • Ask patients what is most important to them — what they would most like help with today • Invite their ideas and input on ways to improve care, programs and services • Teach patients how to navigate the health care system	(see also materials in Individualized Assessment and Goal Setting) Tools from the Diabetes Initiative Guide to Stage of Change Interventions TTM Provider Cards TTM Brochures Patient Health Record Book Program Evaluation Telephone Survey How to Conduct a "Walk-About" from the Patient and Family Perspective Ask me 3 Partnering with Patients and Families
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7. Patient Social Support
Improvement Strategies	Resources and Tools
• Routinely assess patient social support as part of individualized assessment • Involve family members, as appropriate, in supporting patients’ self management plans • Offer group visits to enhance education and provide support	Assessment Tools from the Diabetes Initiative Group visits Group Visit Starter Kit, Marshall University Group Visit Starter Kit, GroupHealth Shared Medical Appointments/ Group Visits, Dartmouth Building Peer Support Programs to Manage Chronic Disease: Seven Models for Success from the California Healthcare Foundation
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8. Linking to Community Resources
Improvement Strategies	Resources and Tools
• Establish referral resources in the community that support patient self management behaviors (e.g., YMCA’s, prescription assistance programs, etc) • Enlist key community organizations in planning relevant services • Create and develop procedures to maintain lists/ database of key community resources • Develop processes of communication with community resource partners • Provide patients and family members schedules and contact information for targeted services • Write “prescriptions” for use of community resources to encourage participation • Work with community partners on walkability or bikeability assessments	Tools for Building Clinic-Community Partnerships to Support Chronic Disease Control and Prevention Sample needs assessments from the Diabetes Initiative Community Organization Questionnaire Employers Questionnaire Pedestrian and Bicycle Information Center’s Walkability Checklist Bikeability Checklist External Mapping Worksheet from Clinical Microsystems Identify Community Resources: New Health Partnerships Establishing a Community-Based DSME Program for Adults with Type 2 Diabetes to Improve Glycemic Control by the Partnership for Prevention MD LINK: Partnering Physicians With Community-Based Organizations, A Toolkit to Help Physicians Educate Their Colleagues on Collaborating with Community-Based Organizations That Serve Older Adults
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Organizational Support

1. Continuity of Care
Improvement Strategies	Resources and Tools
• Schedule planned visits • Ensure each patient has a primary care provider/ medical home • Involve all members of the patient care team in the care plan	Medical Home Assessment Tool (AAFP) The Patient Centered Medical Home (Robert Graham Center) Standards and Guidelines for Physician Practice Connections®— Patient-Centered Medical Home (NCQA) Discharge Preparation Checklist (The Care Transitions Program)
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2. Coordination of Referrals
Improvement Strategies	Resources and Tools
• Establish linkages with key specials to ensure access to expert support • Develop reciprocal communication procedures • Track incomplete referrals and follow up	National Quality Forum-endorsed Definition and Framework for Measuring Care Coordination Example from the Diabetes Initiative Policies and Procedures for Referring Patients
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3. Ongoing Quality Improvement
Improvement Strategies	Resources and Tools
• Choose benchmarks by which the team will assess progress • Use registries or EMRs to routinely track key indicators • Use the registry to provide feedback to care teams • Incorporate collaborative self management models into quality improvement initiatives	Assessment of Primary Care Resources and Supports for Chronic Disease Self Management (PCRS) from the Diabetes Initiative IHI Model for Improvement Clinical Microsystems Outpatient Primary Care Workbook: Assessing, Diagnosing and Treating Your Outpatient Primary Care Practice Learning Modules from The Healthcare Improvement Skills Center
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4. System for Documentation of Self management Support Services
Improvement Strategies	Resources and Tools
• Develop processes for use of registries/ EMRs • Designate staff responsible for entering, checking and maintaining these systems • Use the data to review care and plan visits	Assessment of Chronic Illness Care, especially section 3d related to integration http://www.improvingchroniccare.org/downloads/acic_v3.5a.pdf http://www.improvingchroniccare.org/downloads/completing_and_scoring_the_acic.pdf
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5. Patient Input
Improvement Strategies	Resources and Tools
• Use surveys, focus groups, or patient advisors to solicit input on policies, programs and services • Include patients or family members in improvement projects or on improvement teams	The Patient Assessment of Chronic Illness Care (PACIC ) Consumer Assessment of Healthcare Providers and Systems (CAHPS) Resources from The Institute for Family-Centered Care Advancing the practice of patient- and family-centered ambulatory care: how to get started Patients and Families as Advisors in Primary Care Partnering with Patients and Families to Design a Patient and Family-Centered Health Care System: Recommendations and Promising Practices Partnering with Patients and Families to Enhance Safety and Quality: A Mini Toolkit Selecting, Preparing, And Supporting Patient And Family Advisors In Primary Care (New Health Partnerships)
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6. Integration of Self management Support into Primary Care
Improvement Strategies	Resources and Tools
• Build supports for self management into the practice’s strategic plan • Regularly monitor self management indicators • Seek senior leadership support for improvement efforts through provision of resources and incentives for quality self management	Resources from New Health Partnerships Supporting Patient Self-Management: Self-Assessment Checklist Partnering in Self-Management Support: A Toolkit for Clinicians Delivery System Design Health Care Organization Building Peer Support Programs to Manage Chronic Disease: Seven Models for Success from the California Healthcare Foundation
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7. Patient Care Team
Improvement Strategies	Resources and Tools
• Define roles and responsibilities of each member on the team to ensure efficiency and complementarity • Establish mechanisms for routine communication among members; conduct regular team meetings • Cross-train members of the team	Building Teams in Primary Care: Lessons Learned (California HealthCare Foundation) Planned Visits Improving Chronic Illness Care New Health Partnerships Electronic Health Records versus Chronic Disease Management Systems: A Quick Comparison (California HealthCare Foundation) *Outpatient Primary Care Workbook: Assessing, Diagnosing and Treating Your Outpatient Primary Care Practice* (Clinical Microsystems) Diabetes Team Care Toolkit (California Diabetes Program) Team Care (Better Diabetes Care)**
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8. Physician, Team and Staff Self management Education & Training
Improvement Strategies	Resources and Tools
• Provide skill-based training to all team members on health literacy, collaborative goal setting, problem solving and patient centered care (e.g., 5 A’s, motivational interviewing, CDSMP) • Obtain senior leadership support for ongoing training and skill building • Create mechanisms to ensure new team members get training in the self management approach and procedures used by the team	Techniques for Effective Patient Self-Management video (California HealthCare Foundation) Helping Patients Manage Their Chronic Conditions (California HealthCare Foundation) 5 A’s Behavior Change Model (IHI) Brief Negotiation Roadmap Health Literacy Toolkit from the AAFP foundation Choices and Changes: A New Model for Influencing Patient Health Behavior Sources of additional information Institute for Healthcare Communication New Health Partnerships National Center for Cultural Competence Brief Negotiation Method tutorial (Kaiser Permanente) More Than Words Toolkit Series (Hablamos Juntos) AMA Health Literacy Toolkit Vanderbilt Diabetes Center Health Literacy and Numeracy Tools National Networks of Libraries of Medicine Health Literacy Toolkit
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General Resources

The Diabetes Initiative
The mission of the Diabetes Initiative is to improve the health and quality of life of people with diabetes through advancing diabetes self management systems and services in primary care and community settings. This site offers program models, tools, resources, and lessons learned from the Initiative for supporting self management.
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Institute for Healthcare Improvement
The Institute for Healthcare Improvement (IHI) is an independent not-for-profit organization helping to lead the improvement of health care throughout the world. IHI works to accelerate improvement by building the will for change, cultivating promising concepts for improving patient care, and helping health care systems put those ideas into action. This site offers a variety of tools and products. The Topic section features the best available knowledge for improvement in a given area, including tools, literature, and changes that you can implement and measure to help speed improvement.
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Institute for Family-Centered Care
In partnership with patients, families, and health care professionals from many disciplines, the Institute for Family-Centered Care promotes the understanding and practice of patient- and family-centered care. The Institute seeks to ensure that principles of patient- and family-centered care are reflected in all systems providing care and support to individuals and families including health, education, mental health, and social services. This site has a section on primary care http://www.familycenteredcare.org/advance/topics/primary-care.html that links to a number of helpful primary care resources.
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Health Disparities Collaboratives
The Health Resources and Services Administration (HRSA) Health Disparities Collaboratives were developed to transform primary health care practices in order to improve the health care provided to everyone and to eliminate health disparities. This website offers training manuals, tools and resources, lessons learned from quality improvement efforts and opportunities to get involved.
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Improving Chronic Illness Care (ICIC)
ICIC is dedicated to improving the experience of chronic illness care for patients and their families. ICIC promotes the use of evidence-based change concepts to enhance care. This site provides comprehensive resources about the Chronic Care Model, which views the patient as a partner with providers in decision-making, participation in care, and quality improvement. Useful tools and strategies for change and evaluation are shared.
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Institute for Healthcare Communication
The mission of the Institute for Healthcare Communication is to advance the quality of healthcare by optimizing the experience and process of healthcare communication through four major activities: education, advocacy, research, and partnerships. Formerly the Bayer Institute for Health Care Communication, this organization creates and disseminates innovative educational programs and services and advocates for the importance of communication as an essential aspect of healthcare.
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National Center for Cultural Competence
This center's mission is to increase the capacity of health and mental health programs to design, implement, and evaluate culturally and linguistically competent service delivery systems. The Center offers numerous online resources for improving primary health care including self-assessment tools, training curricula, promising practices, a searchable database as well as on-site training and education.
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New Health Partnerships
New Health Partnerships is an online community for patients, families, and health care providers dedicated to improving the health care and lives of people with chronic conditions. The site includes profiles of individuals and organizations, resources, best practices, stories and tools for promoting collaborative self-management.
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The Commonwealth Fund
The Commonwealth Fund is a private foundation that aims to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults. A special section of the Fund's website is devoted to their Patient-Centered Primary Care Initiative launched in 2005.
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