Best Practice Intervention Package - Kansas Foundation for Medical ...

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SELECTED TOOLS AND RESOURCESThe tools in this package are contributed by home health agencies and/orrecommended from other organizations concerned with care of chronic carepatients. They are• available in the BPIP or on the HHQI BPIP Web page (must be logged into access)• available through links to other organization Web sitesAdditionally, look for links to the numerous tools and resources throughout thepackage. Due to the number of tools and resources, it is easy to select too manyresources. It is suggested that you choose carefully which tools you would liketo use and select a few that are best suited for your prioritized interventions. Soplease examine the tools in this BPIP, the tools available through Web links, ortools under Associated Resources on the Cross Settings II BPIP Web page--thenpick and choose what you would like to use!The tools are organized by :• Tools included as part of this package(listed below and begin on page 39)• Tools through other Web links (page33-37) and also on the HHQI BPIPWeb page• Associated Resources (page 38) andalso on the HHQI BPIP Web pageTools may include specific criteria andmay need to be modified for your agencyuse. Some resources may need to beadapted to the home care population. Theexample of the action plan (page 39-40)lists ‘walking around the block’. This maynot be a good example for a homeboundpatient, but does give the clinician andpatient ideas on how to use the form.WVMI & Quality Insights does not advocate anyone particular tool. We simply provide tools associated with a best practice(s) that is in thepublic domain or given to us to share by other organizations or home health agencies.The tools included as part of this package (pages 39-48) are:Tool/ContributorDesigned for:Action PlanPatientsNew Health Partnerships (NHP)Partnering in Self-ManagementSupport: A Toolkit for Clinicians (NHP)is found under Associated Resources andConviction-Confidence RulerNHPBrief Action Planning (B.A.P.) TMChecklistprovides guidance on the Action Plan.PatientsPartnering in Self-ManagementSupport: A Toolkit for Clinicians (NHP)is found under Associated Resources andprovides guidance on the Conviction –Confidence Ruler.Clinicians and patientsThe background of the Brief ActionPlanning Checklist can be found underAssociated Resources: ComprehensiveMotivationalInterventions (CMI): A Pragmatic,B.A.P. is a registered trademark of StevenCole, MDThe B.A.P. Checklist is the core selfmanagementsupport tool of Comprehensive Stepped--Care Application of Motivational- 30 -
Motivational Interventions (CMI) Partnering with Patients and Familiesto Accelerate Improvement: ReadinessAssessmentNHPSelf-HRA --developed to increase patientengagement in self care managementbehaviorsClinician’s Worksheet and HelpfulGuidelines to Consider from theCompleted Patient Self- HRACall Me First Because I CareGirling Health CarePatient Selection Criteria: HomeTelehealth for Heart FailureOne of the Home Telehealth DiseaseManagement Series toolsInterviewing Using Brief Action Planning(B.A.P.)Organizations and TeamsThe Readiness Assessment is an organizationalassessment preparing to include patients andfamilies on teamsSome ideas to maximize use of thesedocuments:• Use NCR paper so original can be leftwith the patient and the copy for themedical record.• Include helpful information on the backof the top (original) page that is left forthe patient. For example (threequestions to ask your physician at everyvisit --see Ask Me 3, agency information,etc.)• Include OASIS –C measures thatcorrelate with the risk items on one ofthe back copies. (e.g., “I started homehealth care right after leaving thehospital” --M1032)CliniciansThese tools are often requested by home healthagencies. Many of these tools have been revisedfor this BPIP. A complete list of all the HomeTelehealth Disease Management Series isunder Associated Resources.- 31 -
Page 1: Best PracticeIntervention PackageCr
Page 5 and 6: Quick Start GuideQUICK START GUIDE:
Page 7 and 8: Source: Wu, Shin-Yi and Green, Anth
Page 9: CHRONIC CAREIt may assist leadershi
Page 13 and 14: The Bottom LineLeaders must create
Page 15 and 16: DIABETESCenters for Disease Control
Page 17 and 18: SELF-MANAGEMENT: EMPOWERING THE PAT
Page 19 and 20: What is Patient Activation? How Doe
Page 21 and 22: TELEHEALTHTelehealth encompasses a
Page 23 and 24: Focus Section: Improving Care Trans
Page 25 and 26: Checklist for Agency LeadershipHow
Page 27 and 28: CHECKLIST FOR AGENCY LEADERSHIPASSI
Page 29: CHECKLIST FOR AGENCY LEADERSHIPASSI
Page 33 and 34: Tools/Resources available through W
Page 35 and 36: The four conceptual areas (referred
Page 37 and 38: and steps toward them.Self-Efficacy
Page 39 and 40: 1. Goals: Something you WANT to do:
Page 41 and 42: Conviction Ruler0 1 2 3 4 5 6 7 8 9
Page 43 and 44: Partnering with Patients and Famili
Page 45 and 46: Are You at Risk for Going to the Ho
Page 47 and 48: Call Me First!Stay safe and well at
Page 49 and 50: SUCCESS STORIESThere are three succ
Page 51 and 52: Promoting Telehealth as part of a C
Page 53 and 54: TRACKING DATA AND MEASURING PROGRES
Page 55 and 56: Best Practice Intervention Package
Page 57 and 58: Therapy Track: Focus on Improving C
Page 59 and 60: Home Health Aide Track: Focus on Im
Page 61 and 62: Coleman, E.A. (2003). Falling throu
Page 63: http://www.fda.gov/downloads/Medica

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