Transcript No Slide Title

Team/Organization Name
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•
•
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Background and structure
Location
Brief system information (type, size)
Pilot population
Aims Statement
Measures
Community
Resources and Policies
SelfManagement
Support
Informed,
Activated
Patient
Health System
Organization of Health Care
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes
Community
Resources and Policies
Self-Management
Support
• Emphasize Patient
Role
• Assessment
• Interventions
• Care planning and
problem solving
Health System
Organization of Health Care
Delivery
System
Design
• Team roles
and tasks
• Planned visits
• Continuity
• Follow-up
Decision
Support
• Guidelines
• Specialty
interaction
• Provider
education
• Guidelines
for patients
Clinical
Information
Systems
• Registry
• Care reminders
• Patient
Subgroups
• Care planning
Community
Resources and Policies
•Effective programs
•Partnerships
•Coordination
Informed,
Activated
Patient
Health System
Organization of Health Care
•Goals
•Benefits
•Provider incentives
•Improvement strategy
•Senior leaders
Productive
Interactions
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes
Informed,
Activated
Patient
Productive
Interactions
Prepared
Practice
Team
Describe Key Changes made. For example:
•Assessment of selected clinical priorities
•Evidence-based interventions targeted based on assessment
•Protocols used
•Collaborative plan formulated with each participant, based on
PCP input and participant’s readiness
•Self-management support was emphasized
•Proactive follow-up for one year
Functional and Clinical
Outcomes
• List results achieved toward targeted
measures
Actual
– HbA1c < 8.0
– Self-management goals
65%
25%
Target
60%
50%
Strategy for Spread
• Brief description of your spread approach,
including population, site and/or different
diseases
Barriers
• Describe challenges here
Keys to Success
• This is a place to summarize the lessons you
learned