Chronic care


Adherence Readiness Assessment 01/05/09

This assessment form is used to help a patient/client be more adherent to their HIV medications by identifying possible barriers and helping the client overcome them.

When it is determined that a patient/client needs to begin HIV medication based on their CD4 and viral load, the client and provider should complete this form in its entirety at the initial assessment visit. This readiness form is divided into the following assessments:

  • Mental health
  • ...
A Guide to Quality in Consumer-Directed Services 12/10/08

This guide is designed to provide States and programs involved in consumer-directed services for individuals with disabilities with a practical handbook on ensuring and improving the quality of services.

The guide presents a systematic approach for linking planning and quality in consumer-directed systems. It also focuses on the development of quality monitoring and improvement strategies.

It is based on a philosophy that the views of the major program stakeholders—...

Hispanic Diabetes Disparities Learning Network in Community Health Centers 11/25/08

This report describes the Decreasing Disparities Strategy Workgroup's development of a learning network project that included interventions and needs assessments at community health centers to help reduce the diabetes disparity in the Hispanic population.
The report includes:

  • Project description
  • Structure of the learning network
  • Evaluation design
  • Self-management training for Montgomery County Primary Care Coalition clinics
  • Appendixes...
Braden Scale for Predicting Pressure Sore Risk 11/25/08

This rating scale for nurses and other health care providers predicts a patient’s level of risk for developing pressure ulcers. The scale is composed of six subscales that measure functional capabilities of the patient that contribute to either higher intensity and duration of pressure or lower tissue tolerance for pressure.

The six subscales include:

  • Sensory perception
  • Moisture
  • Activity
  • Mobility
  • Nutrition
  • Friction and... 11/25/08

This free online resource for managers, occupational health providers, benefits and human resource managers, and employees helps companies assess the impact of diabetes and the need for education in the workplace. Information on the Web site also helps employees with or at risk for diabetes manage their diabetes while at work and teaches them how to reduce their risk for further complications.

The site includes the following information:

  • Getting started
    • Making...
TriCentral Palliative Care Program Toolkit 11/12/08

The TriCentral Palliative Care (TCPC) Program Toolkit provides a step-by-step guide on how to create an innovative outpatient palliative care program within a health care institution. The toolkit provides a blueprint based on the Kaiser Permanente TCPC program. It includes guidelines for modifying the program to fit an organization’s structure and to meet the needs of patients in the local community.

Contents include:

  • Introduction to the TCPC program
  • ...
CAREWare 11/10/08

CAREWare is a free, easy-to-use, standardized tool for HIV/AIDS service providers to collect client information. It can monitor quality of care at clinics, maintain schedules, track how clients use medications, and produce required reports. The Health Resources and Services Administration developed the software to enable service providers funded by the Ryan White HIV/AIDS Program to complete required data reports detailing information on the clients they serve. However, any providers working...

Integrating Chronic Care and Business Strategies in the Safety Net: A Toolkit for Primary Care Practices and Clinics 10/31/08

This toolkit is for safety net providers interested in implementing the Chronic Care Model (CCM) effectively and sustainably at their organizations while attending to their financial realities. The toolkit provides a step-by-step practical approach to guide primary care teams through four phases of quality improvement.

The toolkit:

  • Sequences and describes the specific practice changes involved in CCM implementation
  • Integrates strategies designed to improve the...
Treating Adolescents with HIV: Tools for Building Skills in Cultural Competence, Clinical Care, and Support 10/31/08

This interactive series of online training modules is designed for health care providers working with human immunodeficiency virus (HIV)-infected youth. The course is presented from the perspective of a culturally aware care provider. Throughout the course, practical tools are provided to assist with “operationalizing” culturally sensitive best practices in the clinic setting.

Modules include:

  • Fundamentals of adolescent care and cultural competence
  • Psychosocial...
Keeping Kidney Patients Safe: Patient Safety Improvement Toolkit 10/15/08

This toolkit includes information, planning tools, and promotional materials to assist in planning and executing a safety improvement program to help fulfill the Centers for Medicare and Medicaid Services conditions for coverage for end stage renal disease (ESRD) facilities.

  • Planning tools:
    • Patient safety improvement plan basics
    • Staff activity planning guide
    • ESRD patient safety annotated bibliography
  • Promotional materials:
    • ...


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