Appendix B. Partner Tools

Integrating Chronic Care and Business Strategies in the Safety Net: A Toolkit for Primary Care Practices and Clinics

The following tools are copyright of author organization. Reproduced and distributed by the Agency for Healthcare Research and Quality (AHRQ) by permission.

1.1

Forming the Team (guide)

Institute for Healthcare Improvement: Forming the Team [Web Page]. Available at: http://www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementFormingtheTeam.aspx.

Seven Leadership Leverage Points (white paper)

Institute for Healthcare Improvement: Seven Leadership Leverage Points for Organization-Level Improvement in Health Care [Web Page]. http://www.ihi.org/knowledge/Pages/IHIWhitePapers/SevenLeadershipLeveragePointsWhitePaper.aspx.

Zen of Teams (presentation)

Zen of Teams. Buttress, S and Yee, R. Zen of Teams. [Web Page] Created for Redefin Phase 2, Learning Session 1. Event Date: March 10, 2005. Available at: http://www.improvingchroniccare.org/downloads/1.1_zen_ofteams.ppt.

1.2

Chronic Care Model Primer (guide)

Improving Chronic Illness Care: Practice Change: Steps for Improvement [Web Page]. Available at: http://www.improvingchroniccare.org/index.php?p=Models&s=98. Accessed August 2008.

A Model for Accelerating Improvement (online)

Institute for Healthcare Improvement Quality Improvement Resources: A Model for Accelerating Improvement [Web Page]. Available at: http://www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx.

Going Lean in Healthcare (white paper)

Institute for Healthcare Improvement: Going Lean in Health Care [Web Page]. Available at: http://www.ihi.org/knowledge/Pages/IHIWhitePapers/GoingLeaninHealthCare.aspx.

2.1

Patient Assessment of Chronic Illness Care

Patient Assessment of Chronic Illness Care: Improving Chronic Illness Care [Web Page] Available at: http://www.improvingchroniccare.org/index.php?p=PACIC_Survey&s=36.

Patient Assessment of Chronic Illness Care Scoring Guide: Improving Chronic Illness Care [Web Page] Available at: http://www.improvingchroniccare.org/index.php?p=Scoring&s=226.

CAHPS® Adult Primary Care Survey

CAHPS® Clinician and Group Survey Adult Primary Care Questionnaire.

Primary Care Staff Satisfaction Survey

Clinical Microsystems [Web Page]. Available at: http://www.clinicalmicrosystem.org. Accessed March 2007.

Assessment of Chronic Illness Care

Assessment of Chronic Illness Care: Improving Chronic Illness Care [Web page]. Available at: http://www.improvingchroniccare.org/index.php?p=ACIC_Survey&s=35.

Assessment of Chronic Illness Care Scoring Guide: Improving Chronic Illness Care [Web page]. Available at: http://www.improvingchroniccare.org/index.php?p=ACIC_Survey&s=35.

Primary Care Practice Know Your Processes (survey)

Primary Care Practice Know Your Processes. Adapted from Assessing, diagnosing, and treating your outpatient primary care practice. [Web Page]. Available at: Clinical Microsystems (Dartmouth College). http://clinicalmicrosystem.org/materials/workbooks/.

Finance Collaborative Pre-Work (survey)

Finance Collaborative Prework Survey. Health Disparities Collaboratives. Finance Redesign.

Building Your Community (guide)

Understand Your Community: Building Your Community: An Asset Based Community Development Toolkit [Web Page]. Available at: http://www.communitybuilders.nsw.gov.au/index.cgi?ID=33&TYPE=num&PG=1&RES=10&SORTBY=1.

2.2

National Disease Guidelines (online)

National Voluntary Consensus Standards for Ambulatory Care—Reports—Publications—National Quality Forum [Web Page]. Available at: http://www.qualityforum.org/publications/reports/ambulatory_care.asp.

National Voluntary Consensus Standards for Ambulatory Care (measures)

National Voluntary Consensus Standards for Ambulatory Care—Reports—Publications—National Quality Forum [Web Page]. Available at: http://www.qualityforum.org/publications/reports/ambulatory_care.asp.

Redesign and Finance Measures

St. Andre C. Redesign and finance change package. Rockville, MD: Health Disparities Collaborative; 2006.

2.3

Chronic Disease Registries: A Product Review (online)

Simon J, Powers M. Chronic Disease Registries: A Product Review. Oakland: California HealthCare Foundation; 2004 [Web Page]. Available at: http://www.chcf.org/publications/2004/05/chronic-disease-registries-a-product-review.

CDEMS Registry (online)

CDEMS User Network (Web site). Available at: The CDEMS User Network: http://www.cdems.com/.

Executive Review of Improvement Projects (white paper)

Reinertsen J, Pugh M, Nolan T. Executive Review of Improvement Projects: A Primer For CEOs and Other Senior Leaders. Rockville, MD: Health Disparities Collaborative; 2005.

Quantitative Diabetes Monthly Report Template (worksheet)

Adapted from Learning Session One: BTS Collaborative Training & Materials: Improving Chronic Illness Care [Web Page]. Available at: http://www.improvingchroniccare.org/index.php?p=Learning_Session_One&s=119.

Narrative Monthly Report Template (worksheet)

Adapted from Learning Session One: BTS Collaborative Training & Materials: Improving Chronic Illness Care [Web Page]. Available at: http://www.improvingchroniccare.org/index.php?p=Learning_Session_One&s=119.

3.1

High Functioning Clinical Teams are Extremely Efficient (presentation)

Moore, LG and Safford, B. High functioning clinical teams are extremely efficient: how to get one and achieve advanced access. Created for Institute for Healthcare Improvement 2004. Available at http://www.improvingchroniccare.org/index.php?p=Critical_Tools&s=162. Accessed September 2008.

Project Planning Form (worksheet)

Adapted from Learning Session One: BTS Collaborative Training & Materials: Improving Chronic Illness Care [Web Page]. Available at: http://www.improvingchroniccare.org/index.php?p=Learning_Session_One&s=119.

Converting Guidelines to Practice (guide)

Improving Chronic Illness Care: Practice Change: Steps for Improvement [Web Page]. Available at: http://www.improvingchroniccare.org/index.php?p=Models&s=98.

Plan Do Study Act Self Management Support Example

Adapted from Learning Session One: BTS Collaborative Training & Materials: Improving Chronic Illness Care [Web Page]. Available at: http://www.improvingchroniccare.org/index.php?p=Learning_Session_One&s=119.

Cross Train Staff (guide)

Optimize the Care Team: Cross-Train Staff [Web Page]. Available at: Institute for Healthcare Improvement. http://www.ihi.org/knowledge/Pages/Changes/OptimizetheCareTeam.aspx.

Team Effectiveness Exercise (survey)

Mohr, Julie. Clinical Microsystem Assessment Tool. Adapted from Assessing, Diagnosing and Treating Your Outpatient Primary Care Practice [Web Page]. Available at: Clinical Microsystems. http://dms.dartmouth.edu/cms/materials/workbooks/outpatient_primary_care.doc.

3.1 and 4.1

Primary Care Practice High Level Flowchart (worksheet)

Adapted from Assessing, Diagnosing and Treating Your Outpatient Primary Care Practice [Web Page]. Available at: Clinical Microsystems: http://dms.dartmouth.edu/cms/materials/workbooks/outpatient_primary_care.doc.

Plan Do Study Act Worksheet

Plan-Do-Study-Act (PDSA) worksheet [Web Page]. Available at: Institute for Healthcare Improvement. http://www.ihi.org/knowledge/Pages/Tools/PlanDoStudyActWorksheet.aspx.

3.2

Panels and Panel Equity (guide)

Tantau & Associates. Understanding Panels in Primary Care [Web Page]. Available at: Institute for Healthcare Improvement. http://www.ihi.org/knowledge/Pages/Tools/UnderstandingPanelsinPrimaryCare.aspx.

Practice Supply Worksheet

Batalden P, Godfrey M, and Nelson G. Institute for Healthcare Improvement: Practice Supply Worksheet [Web Page]. Available at: http://www.ihi.org/knowledge/Pages/Tools/PracticeSupplyWorksheet.aspx. Accessed March 2007.

Daily Demand (guide)

Daily demand [Web Page]. Available at: Institute for Healthcare Improvement. http://www.ihi.org/knowledge/Pages/Measures/DailyDemand.aspx.

3.3

Health Literacy and Patient Safety: Manual for Clinicians (guide)

Weiss BD. Health Literacy and Patient Safety: Manual for Clinicians [Web Page]. Available at: American Medical Association Foundation and American Medical Association. http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf.

Depression Management Tool Kit (online)

Depression management toolkit (PHQ-9, Appendix I, p. 17). MacArthur Initiative on Depression & Primary Care [Web Page]. Available at: http://www.depression-primarycare.org/clinicians/toolkits/.

Spanish PHQ-9 (survey)

Patient Health Questionnaire PHQ-9 for Depression (Spanish). MacArthur Initiative on Depression & Primary Care.

3.3 and 3.4

Shared Care Plan (patient material)

Shared care plan [Web site]. Available at: Whatcom Health Information Network. https://www.sharedcareplan.org/HomePage.aspx.

3.3 and 3.5

Helping Patients Manage Their Chronic Conditions (online)

Bodenheimer T, MacGregor K, Sharifi C. Helping Patients Manage Their Chronic Conditions. Oakland: California Healthcare Foundation; 2005 [Web Page]. Available at: http://www.chcf.org/publications/2005/06/helping-patients-manage-their-chronic-conditions.

3.4

Organizing the Planned Visit (guide)

Improving Chronic Illness Care: Practice Change: Steps for Improvement [Web Page]. Available at: http://www.improvingchroniccare.org/index.php?p=Planned_Visits&s=48. (November 2011).

System Changes and Interventions: Planned Care (presentation)

Improving Chronic Illness Care: System Changes and Interventions: Planned Care [Web Page]. Available at: http://www.improvingchroniccare.org/index.php?p=Presentations&s=230.

Diabetes Standing Orders (worksheet)

Standing orders: diabetes mellitus type II. Olympia, WA: Providence St. Peter Family Medicine Residency Program at Providence St. Peter Family Medicine [Web Page]. Available at: http://www.diabetesinitiative.org/resources/topics/TopicGenAdmin.summary19-PROV.html.

Open Access—Open Office (patient material)

Open Access—Open Office. Sample Open Access Mailer. St. Peter Family Medicine. Olympia, WA. Available at: http://www.improvingchroniccare.org/index.php?p=Critical_Tools&s=162. Accessed September 2008.

Front Desk Collections Flow Chart (guide)

Front Desk Collections Flow Chart.

Huddle Sheet (worksheet)

Batalden P, Godfrey M, and Nelson G. Institute for Healthcare Improvement: Huddle Sheet [Web Page]. Available at: http://www.ihi.org/knowledge/Pages/Tools/Huddles.aspx. Accessed September 2008.

Getting Paid: Maximizing Collections (presentation)

Getting Paid: Maximizing Collections. RedeFin II; 2005 April 13.

Group Visit Starter Kit (guide)

Group Visit Starter Kit. Seattle: Group Health Cooperative; 2001 [Web Page]. Available at: Improving Chronic Illness Care. http://www.improvingchroniccare.org/index.php?p=Toolkits_&_Manuals&s=162.

Group Visit Financials (worksheet)

Group Visit Financials. Created by Providence Health System. Washington. Available at: http://www.improvingchroniccare.org/index.php?p=Critical_Tools&s=162. Accessed September 2008.

3.5

Understanding Goal Setting & Action Planning (guide)

Adapted from Lorig K, Sobel D, Gonzalez V, et al. Living a Healthy Life With Chronic Conditions: Self-Management of Heart Disease, Arthritis, Diabetes, Asthma, Bronchitis, Emphysema, and Others. Third Edition. Boulder, CO: Bull Publishing Company, 2006. Available at: http://www.improvingchroniccare.org/index.php?p=Critical_Tools&s=162. Accessed September 2008.

Agenda Setting Tool: Bubble Diagram (patient material)

Agenda Setting Tool: Bubble Diagram. Author unknown. Available at: http://www.improvingchroniccare.org/index.php?p=Critical_Tools&s=162. Accessed September 2008.

World Education (online)

Health & Literacy Special Collection. Available at: http://healthliteracy.worlded.org.

Diabetes Initiative (online)

Diabetes Initiative [Web site]. Available at: http://www.diabetesinitiative.org.

"5 A's" Behavior Change Model

5 A's Behavior Change Model Adapted for Self-Management Support Improvement [Web Page]. Available at Institute for Healthcare Improvement: http://www.ihi.org/knowledge/Pages/Publications/5AsBibliography.aspx.

4.1

Change Flow Chart (guide)

Wagner, EH. Change Flow Chart. Improving Chronic Illness Care 2007. Available at: http://www.improvingchroniccare.org/index.php?p=Critical_Tools&s=162. Accessed September 2008.

How Hot Are Your Improvement Action Plans PDSAs (worksheet)

How Hot Are Your Improvement Action Plans: Critical Tools [Web Page]. Available at Improving Chronic Illness Care: http://www.improvingchroniccare.org/index.php?p=Critical_Tools&s=162.

4.2

Pay For Performance

Dudley RA, Rosenthal MB. Pay for Performance: A Decision Guide for Purchasers. Rockville, MD: Agency for Healthcare Research and Quality; 2006. AHRQ Pub. No. 06-0047 [Web Page]. Available at: http://www.ahrq.gov/qual/p4pguide.htm.

Advanced Topics

The CAHPS® Improvement Guide

The CAHPS® Improvement Guide: Practical Strategies for Improving the Patient Care Experience [Web Page]. Available at: Agency for Healthcare Research and Quality. https://cahps.ahrq.gov

Redesign and Finance Change Package (guide)

St. Andre C. Redesign and Finance Change Package. Rockville, MD: Health Disparities Collaborative; 2005.

Return to Contents

Current as of August 2008
Internet Citation: Appendix B. Partner Tools: Integrating Chronic Care and Business Strategies in the Safety Net: A Toolkit for Primary Care Practices and Clinics. August 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/primary-care/businessstrategies/busstratapb.html