Put Key Practice Foundations in Place for [Target]

Other Change Package Pages: Change Package Home; Implement Population Management for [Target]; Use All Care Steps to Better Manage [Target]; Case Studies

Below are foundational activities helpful for addressing [Target] across the practice, and tools that can help with this work. Patient-facing tools to implement many of these approaches (e.g., patient self-management, medication adherence) can be found on the Use all Care Steps page. Approaches and tools that support panel-wide [Target] efforts (e.g., using registries) can be found on the Population Management page. For examples of how practices have systematically improved [Target], see the Case Studies page.

Make [Target] a Practice Priority

• Designate a [Target] champion in the practice
  • Cardiovascular Champion Role Description (Kaiser Permanente) [PDF and Additional Context]
• Ensure care team engagement in [Target]
  • Guidance on Providing Team-based Care for Patients with HTN (WA Dept. of Health, HTN Improvement Tool excerpt) [PDF]

Systematically Use Evidence-based Guidelines and Protocols for [Target]

• Implement [Target] guidelines effectively, using the most appropriate information and recommendations
  • ACC Blog Post about Controversies Associated with 2013 HTN Recommendations from former JNC8 Panel Members [webpage]
• Deploy [Target] protocols and algorithms
  • Template for HTN Treatment Protocol, and Examples from Veteran's Affairs, Kaiser Permanente, Institute for Clinical Systems Improvement, and New York City Health and Hospital Corporation (Million Hearts®) [webpage]
  • Health Center HTN Clinical Pathway and Implementation Results (WMYHC) [PDF]

Implement Policies and Procedures for [Target]

• Develop [Target] policies and procedures
  • BP Check Visit Policy and Procedure (Kaiser Permanente) [PDF]*
• Leverage local Patient Centered Medical Home (PCMH) activities to help drive comprehensive approach to [Target]
  • PCMH Change Concepts, Ideas, and Resources (WA Dept. of Health, HTN Improvement Tool excerpt) [PDF]
• Develop a flowchart for how patients with [Target Condition] will be proactively tracked and managed
  • Idealized Critical Pathway [encounter-related] for HTN Control (HRSA) [webpage; scroll down to flow diagram]
  • Planned Care Visit Workflow: diabetes sample, can be adapted for HTN control (within IHI Self-management Toolkit) [PDF]

Train and Evaluate Care Team on Key Skills for [Target]

• Train care team on [key patient-related activities, documentation, and other essential skills related to Target]
  • Checking BP Nursing Competency (Sharp Rees-Stealy Medical Group) [PDF]*
  • BP Measurement: The Proper Way (Cornerstone Health Care) [Video]*
• Evaluate care team members to ensure they can successfully perform [key activities] related to [Target]
  • Competency Checklist BP Measurement (Cleveland Clinic) [PDF]*

Equip Direct Care Staff to Facilitate Patient Self-Management

• Put a prevention, engagement, and self-management program in place [PDF]*; for patient-facing tools, see Provide Educational Materials... in Use All Care Steps page
  • Guide to Helping Patients Monitor their Chronic Conditions (CHCF, 25 pages) [white paper]
  • Toolkit for clinician partnering with patients on self-management (IHI) [webpage]
• Ensure team is skilled in identifying/promoting patient medication adherence; for patient-facing tools, see Support Medication Adherence... in Use All Care Steps page
  • Online guide for providers on promoting medication adherence (ACPM) [webpage]
  • Medication Adherence Action Kit (NYC Dept. of Health) [PDFs - see Provider Resources]

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(c) TMIT Consulting, LLC 2014