Asthma
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Care Management
| Audience |
Item |
Description |
| Physicians/ Clinical Staff/Managers |
Four domains to stratify patients (PDF) |
Using motivational interviewing techniques, the care managers assess patients in four domains to stratisfy patients, determine what level of intervention is appropriate and to assist each patient in developing a patient centered, achievable action plan. |
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COPD
| Audience |
Item |
Description |
| Physicians/ Clinical Staff/Managers |
COPD Resource Guide (WEB) |
Listing of COPD events, study alerts, resources and rehabilitation programs on the Breathe California website. Serving San Mateo, San Francisco, Contra Costa, Marin, Napa, Sonoma, Mendocino, Humboldt, and Del Norte counties in California. |
| Physicians/ Clinical Staff/Managers |
COPD Action Plan for Patients (PDF) |
Patient Self-management action plan from Boehringer-Ingelheim (NCQA DM Program Certified) |
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Depression
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Diabetes
| Audience |
Item |
Description |
| Office Staff/Physicians |
Exam Room Sign (PPT) |
Exam room sign: "If you have Diabetes, please take off your shoes...." (English/Spanish) |
| Physicians/health Educator/Patient |
A1C Patient Education Handout (DOC) |
Patient education handout: "Do you know your A1C number?" |
| Physicians/Health Educator/Patient |
Diabetes Action Plan (English) (DOC) |
1-pg action plan to be completed by patient for goal-setting and self-management education with clinician |
| Physicians/Health Educator/Patient |
Diabetes Action Plan (Spanish) (DOC) |
1-pg action plan to be completed by patient for goal-setting and self-management education with clinician |
| Physicians/Patient |
Basic Diabetes Care Guidelines (PDF) |
Basic guidelines for diabetes care from the California Diabetes Program |
| Physicians |
Diabetes Flow Sheet (DOC) |
Diabetes flow sheet visit form from the California Diabetes Program |
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General Resources
| Audience |
Item |
Description |
| Clinicians/Managers |
HCC Coding Blog (WEB) |
Regularly updated blog on all things related to Medicare Advantage risk adjustment. Author: Matt Yuill, MD, CPC - Founder of SearchICD9.com (another great tool!) and Chief Medical Information Officer of HCC Administrators, Inc. based in Los Angeles |
| Physicians & Office Staff |
Video: Team Meetings in a Clinical Environment (WEB) |
10-minute video produced by CHCF and the California Improvement Network shows how regularly scheduled clinical team meetings can make a difference in team effectiveness, care delivery and provides tips on getting the most from these group interactions |
| Physician Group Leaders |
Disease Registry Products Profile & Pricing Info (PDF) |
Profile of features and pricing for popular disease registry products used by physician groups in the region |
| All |
Improving Chronic Illness Care (WEB) |
Improving Chronic Illness Care program (ICIC) Resource Library offers a range of resources and teaching tools designed for leading and managing improvement efforts within a variety of settings |
| All |
Institute for Healthcare Improvement (WEB) |
Institute for Healthcare Improvement (IHI) is a distinguished independent health improvement organization featuring a variety of topics, including tools, literature, and changes that you can implement and measure to help speed improvement in your organization |
| All |
Institute for Clinical Systems Improvement (WEB) |
Institute for Clinical Systems Improvement (ICSI) is an independent organization that helps its members provide evidence-based health care services to people in Minnesota and surrounding states |
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Medicare Stars Resources
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Patient Self-Management Support
| Audience |
Item |
Description |
| Clinicians/Case Managers |
Video: Techniques for Effective Patient Self-Management (WEB) |
A short training video, produced by the California HealthCare Foundation and William Polonsky, PhD or UCSD, on principles of motivational interviewing, a technique clinicians can use to help patients adopt healthy behaviors |
| Clinicians/Case Managers |
Training Resources (PDF) |
Training resources for Self Management Support |
| Clinician/Patient |
Patient Action Plan (DOC) |
CMS' Action plan tool to guide patients as they select one or two concrete activities to adopt healthier behaviors. |
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