Integrating Chronic Care and Business Strategies in the Safety Net (Coaching Manual)

Appendix of Meeting Agendas and Tools

Example: Practice Team Orientation Call Agenda

Integrating Chronic Care & Business Strategies in the Safety Net

Practice Name:



Dial-in Number:

Conference Code:

Participants: Coaches, medical director of ambulatory care, medical director of the site, administrative director of the site, physician, nurse, medical assistant, front desk staff, local trusted stakeholder.


Event Participants Time
Opening Remarks Key Medical and Administrative Leadership

e.g., Medical Director of Site,

Medical Director of Ambulatory Care Administrative Director of the Site
10 minutes
Introductions All 10 minutes
Overview Coaches 15 minutes
Questions & Answers All 20 minutes
Next Steps Coaches 5 minutes

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Example: Practice Team Site Visit Preparation Call

Integrating Chronic Care & Business Strategies In The Safety Net

Clinic Name:



Dial-in Number:

Conference Code:

Participants: Coaches, medical director of the site, administrative director of the site, physician, nurse, medical assistant, front desk staff.


Event Participants Time
Introductions All 10 minutes
Overview Coaches 5 minutes
Remaining Questions About Project Aims All 10 minutes
Prework Overview

   Clinical data

   Financial data

   Assessment of Chronic Illness Care

   Administrative Process
Coaches 20 minutes
What to expect during the observational assessment Coaches 5 minutes
What to expect during the learning session Coaches 5 minutes
Continued communication All 5 minutes

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Example: Assessment Day Agenda

Integrating Chronic Care & Business Strategies In The Safety Net

Clinic Name:



Dial-in Number:

Conference Code:

Participants: physicians, nurses, medical assistants, administrators, coaches, anyone else the team deemed to be part of their work (e.g., Certified Diabetes Educators, nutritionist, front desk clerk)

Event Participants Time
Team Meeting   1:00—2:00
Introductions All 1:00—1:10
Overview & What To Expect Coaches 1:10—1:40
Remaining Questions All 1:40—1:55
Collect prework, complete "Know Your Process" Coaches 1:55—2:00
Practice Observation 2:00—4:30

Patient perspective

  1. Observe patients—How long does a patient spend waiting for his or her appointment? Does the check-in process work smoothly? Is patient information available in the waiting room at appropriate reading levels and in appropriate languages?

Practice perspective

  1. Talk to team members.
  2. Observe office practice (Tool: see below, Clinical Observation Assessment).

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Tool: Clinic Observation Assessment

Self-Management Support Delivery System Design

ASK! "How do you support patients to manage their __________ on their own?"

What you're looking for:

|__| Emphasize the patient's central role.

|__| Use effective self-management support strategies that include assessment, goal-setting, action planning, problem solving,and followup.

|__| Organize resources to support SMS.

ASK! "Who is in charge of _________?"

"Do you bring your patients regularly for planned visits?"

Observe! Is a case manager part of the team? Is care provided in a culturally competent way?

What you're looking for:

|__| Define roles and distribute tasks among team members.

|__| Use planned interactions to support evidence-based care.

|__| Provide clinical case management services.

|__| Ensure regular followup.

|__| Give care that patients understand and that fits their culture.

Decision Support Clinical Information System

ASK! "How do you get your information about clinical guidelines?"

Observe! Are guideline-based patient materials available?

What you're looking for:

|__| Embed evidence-based guidelines into daily clinical practice.

|__| Integrate specialist expertise and primary care.

|__| Use proven provider education methods.

|__| Share guidelines and information with patients.

ASK! "Do you have a patient registry that is useful in providing clinical information at the point of care?" "How do you monitor your performance?"

What you're looking for:

|__| Provide reminders for providers and patients.

|__| Identify relevant patient subpopulations for proactive care.

|__| Facilitate individual patient care planning.

|__| Share information with providers and patients.

|__| Monitor performance of team and system.

Community Resources and Policies Health Care Organization

ASK! "What community agencies do you all find particularly useful for your patients?"

Observe! Is there a sense that the team members are aware of other resources in the community? Is information about referrals to other organizations readily available?

|__| Encourage patients to participate in effective programs.

|__| Form partnerships with community organizations to support or develop programs.

|__| Advocate for policies to improve care.

Observe! Are senior managers engaged with this project? Are they supportive of the teams? How does the organization handle problems?

|__| Visibly support improvement at all levels, starting with senior leaders.

|__| Promote effective improvement strategies aimed at comprehensive system change.

|__| Encourage open and systematic handling of problems.

|__| Provide incentives based on quality of care.

|__| Develop agreements for care coordination.

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Example: Learning Session Agenda

Integrating Chronic Care & Business Strategies in the Safety Net

Clinic Name:



Dial-in Number :

Conference Code:

Participants: Coaches, medical director of the site, administrative director of the site, physicians, nurses, medical assistants, front desk staff.


  1. Review data.
  2. Learn about the Chronic Care Model, PDSAs, Business Redesign tools.
  3. Identify what changes you want to make.
  4. Plan how to start.
  5. Build team confidence.
Event Participants Time
Reflections on where we are 1:00—2:55
Coach Present the Chronic Care Model

(Tool: Key Change 1.2, Chronic Care Model Primer)
1:00 -1:30
Coaches Review ACIC Scores & discussion

(Tool: Key Change 2.1, Assessment of Chronic Illness Care)
Coach Review "Know your Process" & group discussion

(Tool: Key Change 2.1, Primary Care Practice Know Your Processes)
1:50- 2:10
Coach Present Model for Improvement

(Tool: Key Change 1.2, A Model for Accelerating Improvement)
All Review themes from observational assessment & group discussion 2:40—2:55
Break 2:55-3:10
Where To Start 3:15—4:50
Coach Present "menu" concept of where they might start What's missing? Anything from the data/presentations that wasn't covered?

(Tool: see below, The "Change Your Practice" Menu)
Team Breakout Decide where to start & what you will track monthly List as many PDSAs as you can

(Tool: see below, Getting Started Logistics)

Present business redesign elements from the toolkit & introduce the toolkit as a resource

Introduce monthly report template

(Tool: Key Change 2.3 , Quantitative Monthly Diabetes Report Template and the Narrative Monthly Report Template)



Wrap-Up & Next Steps 4:50—5:00
Coaches Thank you & last minute comments
Teams Complete Coach Evaluation (Tool: see below, Tell Us What You Think!)

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Tool: The "Change Your Practice" Menu

Below are some ideas to begin testing in your practice. These are not meant to be an exhaustive list. You may have other ideas not on this menu. So please do not feel constrained by this menu. It is meant to stimulate thought.

Delivery System Design

  • Conduct team meeting or huddle tomorrow.
  • Assign roles and responsibilities for the care of chronically ill patients.
  • Call patient and conduct a planned visit.

Self-Management Support for Patients

  • Set goal and create action plan at next patient visit.
  • Refer patient to self-management program in community.

Decision Support

  • Use registry data as reminders.
  • Use care coordination agreement with a specialist.
  • Create patient care guidelines wallet card for patient use.

Clinical Information

  • Design process for getting patient information into registry.
  • Use registry population report at team meeting to plan care for patients in the following month.
  • Use a patient summary of information from last visit to drive care at current visit.

Community Resources

  • Contact DOH, ADA, or other patient organizations for patient resources.
  • Connect patients with resources.
  • Discuss potential partnering with outside organizations to create needed services.

Process Efficiencies

  • Develop checklist of all the patient information needed at the time of the visit and brainstorm ways to ensure you get all the info you need before the visit.
  • Create a process map of a visit from the perspective of a patient.

Revenue Optimization

  • Review your coding practices by provider. Are you fully capturing the work you're doing?
  • Review your copay and self-pay policies to ensure that you collect your portion of the cash up front.

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Tool: Getting Started Logistics

1. Who Will be on our Team?

Physician            ________________________________________________________

Nurse / MA        ________________________________________________________

Nurse/ MA         ________________________________________________________

CDE?                 ________________________________________________________

Data guru?          ________________________________________________________

Office manager? ________________________________________________________

Others?              ________________________________________________________



2. What is our Aim?

To improve chronic illness care for patients in the most effective, safe, and efficient way using the Chronic Care Model and business strategies and facilitated by the toolkit and practice coaches.

3. What measures will we look at to know if we're improving? (select no more than 6-8 of the options below, a mix of process and outcome measures)

Process Measures

|__| % of patients with documented self-management support goal

|__| % of patients with 2 HbA1cs in the last year

|__| % of patients with retinal exam

|__| % of patients with foot exam

|__| % of patients who are current smokers

|__| % of patients with influenza vaccination

|__| % of patients with pneumococcal vaccination

|__| % of patients with depression screen in the last 12 months

|__| % of patients with annual dental exam

|__| % of patients 18 to <70 not on ACE/ARB with Microalb Screen in last 12 months*

|__| % of patients 55 & older on ACE/ARB*

|__| % of patients 40 & older on statins*

|__| % of patients 30 & older taking aspirin*

Outcome Measures

|__| % of patients with HbA1c < 7

|__| % of patients with BP < 130/80

|__| % of patients with LDL < 100

* indicates measures requiring a customized denominator. All other measures will use your panel of diabetic patients as the denominator.

4. What data will we need for those measures? How will we collect these?

Most of the measures can be captured from electronic sources, though they may not be completely accurate. The following measures often are not captured electronically so may require designated data entry.

  • Blood pressure.
  • Monofilament foot testing.
  • Self-management support.
  • Smoking status.
  • Depression screening.
  • Patients on aspirin.
  • Annual dental exam.

5. How often/when will we meet?

  • Individually or as a group.
  • Daily huddles or weekly meetings.

6. Plan-do-study-act cycles to get started with:

Description of change Responsibility OCT NOV DEC

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Tool: Tell Us What You Think!


PART 1: Circle the number of the statement you most agree with.

The Trainers .

Were helpful:

      1             2           3            4           5

not at all    a little    sort of    mostly    totally

Knew the topic:

      1             2           3            4           5

not at all    a little    sort of    mostly    totally

Gave us what we needed to get started:

      1             2           3            4           5

not at all    a little    sort of    mostly    totally

Communicated clearly:

      1             2           3            4           5

not at all    a little    sort of    mostly    totally

PART 2: Write any additional comments that may help the trainers improve.

Things I liked:


Things I didn't like:


Other recommendations/comments:

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Page last reviewed October 2014
Page originally created April 2009
Internet Citation: Appendix of Meeting Agendas and Tools. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.