Template for Change Package on an Outpatient Target

[Note: this Template contains some examples related to the Hypertension Control target as sample content - see blue font on linked pages below]

Other Change Package Pages: Put Key Foundations in Place for [Target]; Implement Population Management for [Target]; Use All Care Steps to Better Manage [Target]; Case Studies

[Improvement Target] Overview and Change Package Contents

The purpose of this change package is to guide healthcare practices in improving patient care by addressing [Target Condition] more efficiently and effectively. It outlines activities (see heading A below) and includes materials and examples (see pages linked to headings 1, 2, and 3 under A) that practices can adapt to achieve three requirements for this goal:

• Putting in place practice foundations for improving [Target]
• Managing [Target] better across the practice's patient population
• Leveraging all care steps to help the care team manage [Target] better in interactions with individual patients

Under each of these headings below are change concepts that practices can consider to drive targeted improvement. On pages linked to from the headings, there are additional change ideas that provide further detail about implementing each change concept. Underneath change ideas on those linked changes - in blue font - are specific tools that can be used to translate the change idea into action.

For example, this [Hypertension control] change package includes tools to help implement evidence-based approaches including:

• [implement policies that ensure BP is addressed at every patient encounter with the practice,
• use registries and dashboards to monitor and manage HTN across all patients cared for by the practice
• ...]

This change package also highlights case studies (see heading B below) that illustrate how practices have successfully used systematic approaches and tools to achieve exemplary performance on [Target].

A. Steps for Practices to Improve [Target] (Click links for more details and tools)

1. Put Key Foundations in Place for [Target]

• Make [Target] a Practice Priority
• Systematically Use Evidence-based Guidelines and Protocols [Target]
• Implement Policies and Procedures for [Target]
• Train and Evaluate Care Team on Key Skills for [Target]
• Equip Direct Care Staff to Facilitate Patient Self-Management

2. Implement Population Management for [Target]

• Use a Registry to Identify, Track, and Manage Patients with [Target Condition]
• Use Clinician-managed Protocols for Medication Adjustment and Lifestyle Recommendations
• Use Practice Data to Drive Improvement

3. Use All Care Steps to Better Manage [Target] with Individual Patients

• Support Patients in [Target Condition] Self-management During their Routine Daily Activities
• Prepare Patients and Care Team Beforehand for Effective [Target Condition] Management During Office Visits
• Use Opportunities During Each Patient Visit Phase (e.g., Check-in/waiting, Provider Encounter, Check-out) to Optimize [Target Condition] Management
• Follow Up After Visits to Monitor and Reinforce [Target Condition] Management Plans

B. [Target] Improvement Case Studies

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