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Other Change Package Pages: Change Package Home; Put Key Foundations in Place for [Target]; Use All Care Steps to Better Manage [Target]; Case Studies
This section features population-based activities that support panel-wide [Target] management, and tools that can help practices with this quality improvement (QI) work. For guidance and tools to strengthen foundational practice capabilities (e.g., around evidence-supported [Target] management) see the Foundations page. For guidance and resources on optimizing [Target] via individual patient interactions, see the Use All Care Steps page. For examples of how practices have systematically improved [Target], see the Case Studies page.
Use a Registry to Identify, Track, and Manage Patients with [Target Condition]
- Implement a [Target Condition] registry
- Background information on establishing registries (AMGA) [PDF]*
- Use a defined process for outreach (e.g., via phone, mail, email, text message) to patients with [Target Condition] and those otherwise needing follow-up
- Process for Recalling Patients for Needed HTN Follow-up (RCHC) [PDF]
- Example Patient List from Small Practice Registry (ONC) [scroll down to Figure from the Ellsworth Medical Clinic QI Case Study narrative in the ONC Resources for Improving Care with CDS.]
Use Clinician-managed Protocols for Medication Adjustments and Lifestyle Recommendations
- Use protocols to cover proactive outreach driven by registry use [webpage]
Use Practice Data to Drive Improvement
- Determine [Target] metrics
- HTN Control Metrics (WA Dept. of Health, HTN Improvement Tool excerpt) [PDF]
- HTN Measures Used in a Health Center Network (HCNNY) [PDF]
- Regularly provide a dashboard with [Target] goals, metrics, and performance
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