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Integrating Chronic Care and Business Strategies in the Safety Net

Reference List

1. Center for Disease Control and Prevention. Chronic Disease—Overview [Web Page]. Available at: http://www.cdc.gov/chronicdisease/overview/index.htm. Accessed November 2011.

2. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002 Oct;288(14):1775-9.

3. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the quality chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.

4. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996;74(4 ):511-44.

5. Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? [editorial]. Eff Clin Pract 1998 Aug-1998 Sep;1(1):2-4.

6. Institute for Healthcare Improvement: Forming the Team [Web Page]. Available at: http://www.ihi.org/knowledge/Pages/HowtoImprove/default.aspx. Exit Disclaimer Accessed November 2011.

7. Institute for Healthcare Improvement: Seven Leadership Leverage Points for Organization-Level Improvement in Health Care [Web Page]. http://www.ihi.org/knowledge/Pages/IHIWhitePapers/SevenLeadershipLeveragePointsWhitePaper.aspx. Exit Disclaimer Accessed November 2011.

8. Buttress, S and Yee, R. Zen of Teams. [Web Page] Created for Redefin Phase 2 Learning Session 1 Event Date: March 10, 2005.

9. Improving Chronic Illness Care: Practice Change: Steps for Improvement [Web Page]. Available at: http://www.improvingchroniccare.org/index.php?p=Models&s=98. Exit Disclaimer Accessed August 2008.

10. Institute for Healthcare Improvement Quality Improvement Resources: A Model for Accelerating Improvement [Web Page]. Available at: http://www.ihi.org/Pages/default.aspx. Exit Disclaimer Accessed November 2011.

11. Institute for Healthcare Improvement: Going Lean in Health Care [Web Page]. Available at: http://www.ihi.org/knowledge/Pages/IHIWhitePapers/GoingLeaninHealthCare.aspx. Exit Disclaimer Accessed November 2011.

12. Patient Assessment of Chronic Illness Care: Improving Chronic Illness Care [Web Page] Available at: http://www.improvingchroniccare.org/index.php?p=PACIC_Survey&s=36. Exit Disclaimer Accessed November 2011.

13. Patient Assessment of Chronic Illness Care Scoring Guide: Improving Chronic Illness Care [Web Page] Available at: http://www.improvingchroniccare.org/index.php?p=Scoring&s=226. Exit Disclaimer Accessed November 2011.

14. CAHPS® Clinician and Group Survey Adult Primary Care Questionnaire.

15. Clinical Microsystems [Web Page]. Available at: http://www.clinicalmicrosystem.org. Exit Disclaimer Accessed March 2007.

16. Assessment of Chronic Illness Care: Improving Chronic Illness Care [Web page]. Available at: http://www.improvingchroniccare.org/index.php?p=ACIC_Survey&s=35. Exit Disclaimer Accessed November 2011.

17. Assessment of Chronic Illness Care Scoring Guide: Improving Chronic Illness Care [Web page]. Available at: http://www.improvingchroniccare.org/index.php?p=ACIC_Survey&s=35. Exit Disclaimer Accessed November 2011.

18. Primary Care Practice Know Your Processes. Adapted from Assessing, diagnosing, and treating your outpatient primary care practice. [Web Page]. Available at: Clinical Microsystems (Dartmouth College). http://clinicalmicrosystem.org/materials/workbooks/. Exit Disclaimer Accessed November 2011.

19. Finance Collaborative Prework Survey. Health Disparities Collaboratives. Finance Redesign.

20. Understand Your Community: Building Your Community: An Asset Based Community Development Toolkit [Web Page]. Available at: communitybuilders.nsw. http://www.communitybuilders.nsw.gov.au/index.cgi?ID=33&TYPE=num&PG=1&RES=10&SORTBY=1. Accessed November 2011.

21. National Guideline Clearinghouse™ [Web site] Available at: Agency for Healthcare Research and Quality. http://www.guideline.gov/. .

22. National Voluntary Consensus Standards for Ambulatory Care—Reports—Publications—National Quality Forum. Accessed November 2011.

23. St. Andre C. Redesign and finance change package. Rockville, MD: Health Disparities Collaborative; 2006.

24. Simon J, Powers M. Chronic Disease Registries: A Product Review. Oakland: California HealthCare Foundation; 2004 [Web Page]. Available at: http://www.chcf.org/publications/2004/05/chronic-disease-registries-a-product-review. Exit Disclaimer Accessed November 2011.

25. CDEMS User Network (Web site). Available at: The CDEMS User Network: http://www.cdems.com/. Accessed November 2011.

26. Reinertsen J, Pugh M, Nolan T. Executive Review of Improvement Projects: A Primer For CEOs and Other Senior Leaders. Rockville, MD: Health Disparities Collaborative; 2005.

27. Adapted from Learning Session One: BTS Collaborative Training & Materials: Improving Chronic Illness Care [Web Page]. Available at: http://www.improvingchroniccare.org/index.php?p=Learning_Session_One&s=119. Exit Disclaimer Accessed November 2011.

28. Adapted from Learning Session One: BTS Collaborative Training & Materials: Improving Chronic Illness Care [Web Page]. Available at http://www.improvingchroniccare.org/index.php?p=Learning_Session_One&s=119. Exit Disclaimer Accessed November 2011.

29. Moore, LG and Safford, B. High functioning clinical teams are extremely efficient: how to get one and achieve advanced access. Created for Institute for Healthcare Improvement 2004. Available at http://www.improvingchroniccare.org/index.php?p=Critical_Tools&s=162. Exit Disclaimer Accessed September 2008.

30. Adapted from Learning Session One: BTS Collaborative Training & Materials: Improving Chronic Illness Care [Web Page]. Available at: http://www.improvingchroniccare.org/index.php?p=Learning_Session_One&s=119. Exit Disclaimer Accessed November 2011.

31. Adapted from Assessing, Diagnosing and Treating Your Outpatient Primary Care Practice [Web Page]. Available at: Clinical Microsystems: http://dms.dartmouth.edu/cms/materials/workbooks/outpatient_primary_care.doc. Exit Disclaimer (Word® File, Plugin Software Help) Accessed November 2011.

32. Improving Chronic Illness Care: Practice Change: Steps for Improvement [Web Page]. Available at: http://www.improvingchroniccare.org/index.php?p=Models&s=98. Exit Disclaimer Accessed November 2011.

33. Plan-Do-Study-Act (PDSA) worksheet [Web Page]. Available at: Institute for Healthcare Improvement. http://www.ihi.org/knowledge/Pages/Tools/PlanDoStudyActWorksheet.aspx. Exit Disclaimer Accessed November 2011.

34. Learning Session One: BTS Collaborative Training & Materials: Improving Chronic Illness Care [Web Page] . Available at: http://www.improvingchroniccare.org/index.php?p=Learning_Session_One&s=119. Exit Disclaimer Accessed November 2011.

35. Optimize the Care Team: Cross-Train Staff [Web Page]. Available at: Institute for Healthcare Improvement. http://www.ihi.org/knowledge/Pages/Changes/OptimizetheCareTeam.aspx. Exit Disclaimer Accessed November 2011.

36. Mohr, Julie. Clinical Microsystem Assessment Tool. Adapted from Assessing, Diagnosing and Treating Your Outpatient Primary Care Practice [Web Page]. Available at: Clinical Microsystems. http://dms.dartmouth.edu/cms/materials/workbooks/outpatient_primary_care.doc. Exit Disclaimer (Word® File, Plugin Software Help) Accessed November 2011.

37. Tantau & Associates. Understanding Panels in Primary Care [Web Page]. Available at: Institute for Healthcare Improvement. http://www.ihi.org/knowledge/Pages/Tools/UnderstandingPanelsinPrimaryCare.aspx. Exit Disclaimer Accessed November 2011.

38. Batalden P, Godfrey M, and Nelson G. Institute for Healthcare Improvement: Practice Supply Worksheet [Web Page]. Available at: http://www.ihi.org/knowledge/Pages/Tools/PracticeSupplyWorksheet.aspx. Exit Disclaimer Accessed March 2007.

39. Daily demand [Web Page]. Available at: Institute for Healthcare Improvement. http://www.ihi.org/knowledge/Pages/Measures/DailyDemand.aspx. Exit Disclaimer Accessed November 2011.

40. Shared care plan [Web site]. Available at: Whatcom Health Information Network. https://www.sharedcareplan.org/HomePage.aspx. Exit Disclaimer Accessed November 2011.

41. Weiss BD. Health Literacy and Patient Safety: Manual for Clinicians [Web Page]. Available at: American Medical Association Foundation and American Medical Association. http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf [PDF File, Plugin Software Help]. Accessed November 2011.

42. Bodenheimer T, MacGregor K, Sharifi C. Helping Patients Manage Their Chronic Conditions. Oakland: California Healthcare Foundation; 2005 [Web Page]. Available at: http://www.chcf.org/publications/2005/06/helping-patients-manage-their-chronic-conditions. Exit Disclaimer Accessed November 2011.

43. Depression management toolkit (PHQ-9, Appendix I, p. 17). MacArthur Initiative on Depression & Primary Care [Web Page]. Available at: http://www.depression-primarycare.org/clinicians/toolkits/. Exit Disclaimer Accessed November 2011.

44. Patient Health Questionnaire PHQ-9 for Depression (Spanish). MacArthur Initiative on Depression & Primary Care [Web Page]. Available at: http://www.depressionprimarycare.org/clinicians/toolkits/materials/forms/phq9/. Accessed November 2011.

45. Improving Chronic Illness Care: Practice Change: Steps for Improvement [Web Page]. Available at: http://www.improvingchroniccare.org/index.php?p=Planned_Visits&s=48. Exit Disclaimer Accessed November 2011.

46. Improving Chronic Illness Care: System Changes and Interventions: Planned Care [Web Page]. Available at: http://www.improvingchroniccare.org/index.php?p=Presentations&s=230 Exit Disclaimer . Accessed November 2011.

47. Standing orders: diabetes mellitus type II. Olympia, WA: Providence St. Peter Family Medicine Residency Program at Providence St. Peter Family Medicine [Web Page]. Available at: http://www.diabetesinitiative.org/resources/topics/TopicGenAdmin.summary19-PROV.html. Exit Disclaimer Accessed November 2011.

48. Open Access—Open Office. Sample Open Access Mailer. St. Peter Family Medicine. Olympia, WA. Available at: http://www.improvingchroniccare.org/index.php?p=Critical_Tools&s=162. Exit Disclaimer Accessed September 2008.

49. Shared Care Plan. Available at: Whatcom Health Information Network (Web site). https://www.sharedcareplan.org/HomePage.aspx. Exit Disclaimer Accessed November 2011.

50. Front Desk Collections Flow Chart.

51. Batalden P, Godfrey M, and Nelson G. Institute for Healthcare Improvement: Huddle Sheet [Web Page]. Available at: http://www.ihi.org/knowledge/Pages/Tools/Huddles.aspx. Exit Disclaimer Accessed September 2008.

52. Getting Paid: Maximizing Collections. RedeFin II; 2005 April 13.

53. Group Visit Starter Kit. Seattle: Group Health Cooperative; 2001 [Web Page]. Available at: Improving Chronic Illness Care. http://www.improvingchroniccare.org/index.php?p=Toolkits_&_Manuals&s=162. Exit Disclaimer Accessed November 2011.

54. Group Visit Financials. Created by Providence Health System. Washington. Available at: http://www.improvingchroniccare.org/index.php?p=Critical_Tools&s=162. Exit Disclaimer Accessed September 2008.

55. Bodenheimer T, MacGregor K, Sharifi C. Helping Patients Manage Their Chronic Conditions. Oakland: California Healthcare Foundation; 2005 [Web Page]. Available at: http://www.chcf.org/publications/2005/06/helping-patients-manage-their-chronic-conditions. Exit Disclaimer Accessed November 2011.

56. Adapted from Lorig K, Sobel D, Gonzalez V, et al. Living a Healthy Life With Chronic Conditions: Self-Management of Heart Disease, Arthritis, Diabetes, Asthma, Bronchitis, Emphysema, and Others. Third Edition. Boulder, CO: Bull Publishing Company, 2006. Available at http://www.improvingchroniccare.org/index.php?p=Critical_Tools&s=162. Exit Disclaimer Accessed September 2008.

57. Action plan [Web Page]. Available at: New Health Partnerships. http://www.collaborativeselfmanagement.org/ChangeTool.aspx. Accessed November 2011.

58. Agenda Setting Tool: Bubble Diagram. Author unknown. Available at: http://www.improvingchroniccare.org/index.php?p=Critical_Tools&s=162. Exit Disclaimer Accessed September 2008.

59. Health & Literacy Special Collection. Available at: http://healthliteracy.worlded.org/. Exit Disclaimer Accessed November 2011.

60. Diabetes Initiative [Web site]. http://www.diabetesinitiative.org/. Exit Disclaimer Accessed November 2011.

61. 5 A's Behavior Change Model Adapted for Self-Management Support Improvement [Web Page]. Available at Institute for Healthcare Improvement: http://www.ihi.org/knowledge/Pages/Publications/5AsBibliography.aspx. Exit Disclaimer Accessed November 2011.

62. Wagner, EH. Change Flow Chart. Improving Chronic Illness Care 2007. Available at: http://www.improvingchroniccare.org/index.php?p=Critical_Tools&s=162. Exit Disclaimer Accessed September 2008.

63. Adapted from Assessing, Diagnosing and Treating Your Outpatient Primary Care Practice [Web Page]. Available at: Clinical Microsystems: http://dms.dartmouth.edu/cms/materials/workbooks/outpatient_primary_care.doc. Exit Disclaimer (Word® File, Plugin Software Help) Accessed November 2011.

64. Plan-Do-Study-Act (PDSA) worksheet [Web Page]. Available at: Institute for Healthcare Improvement. http://www.ihi.org/knowledge/Pages/Tools/PlanDoStudyActWorksheet.aspx. Exit Disclaimer Accessed November 2011.

65. How Hot Are Your Improvement Action Plans: Critical Tools [Web Page]. Available at Improving Chronic Illness Care: http://www.improvingchroniccare.org/index.php?p=Critical_Tools&s=162. Exit Disclaimer Accessed November 2011.

66. Kelly-Flis P. Community.

67. Pay For Performance: An Introduction.

68. Dudley RA, Rosenthal MB. Pay for Performance: A Decision Guide for Purchasers. Rockville, MD: Agency for Healthcare Research and Quality; 2006. AHRQ Pub. No. 06-0047 [Web Page]. Available at: http://www.ahrq.gov/qual/p4pguide.htm. Accessed November 2011.

69. The CAHPS® Improvement Guide: Practical Strategies for Improving the Patient Care Experience [Web Page]. Available at: Agency for Healthcare Research and Quality. https://cahps.ahrq.gov. Accessed November 2011.

70. The CAHPS® Improvement Guide: Practical Strategies for Improving the Patient Care Experience [Web Page]. Available at: Agency for Healthcare Research and Quality. https://cahps.ahrq.gov. Accessed November 2011.

71. St. Andre C. Redesign and Finance Change Package. Rockville, MD: Health Disparities Collaborative; 2005.

72. Renders CM, Valk GD, Griffin S, et al. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings (Cochrane Review). Cochrane Database Syst Rev 2002;1:CD001481.

73. Tsai AC, Morton SC, Mangione CM, et al. A meta-analysis of interventions to improve care for chronic illnesses. Am J Manag Care 2005 Aug;11(8):478-88.

74. Fleming B, Silver A, Ocepek-Welikson K, et al. The relationship between organizational systems and clinical quality in diabetes care. Am J Manag Care 2004 Dec;10(12):934-44.

75. Feifer C, Ornstein SM, Nietert PJ, et al. System supports for chronic illness care and their relationship to clinical outcomes. Top Health Inf Manage 2001 Nov;22(2):65-72.

76. Lozano P, Finkelstein JA, Carey VJ, et al. A multisite randomized trial of the effects of physician education and organizational change in chronic-asthma care: health outcomes of the Pediatric Asthma Care Patient Outcomes Research Team II Study. Arch Pediatr Adolesc Med 2004 Sep;158.(9):875-83.

77. Piatt GA, Orchard TJ, Emerson S, et al. Translating the chronic care model into the community: results from a randomized controlled trial of a multifaceted diabetes care intervention. Diabetes Care 2006 Apr;29(4):811-7.

78. Daniel DM, Norman J, Davis C, et al. A state-level application of the chronic illness breakthrough series: results from two collaboratives on diabetes in Washington State. Jt Comm J Qual Saf 2004 Feb;30(2):69-79.

79. Huang ES, Zhang Q, Brown SES, Drum ML, Meltzer DO, Chin MH. The Cost-Effectiveness of Improving Diabetes Care in U.S. Federally Qualified Community Health Centers. HSR. 2007 2007 Dec;42((6 Pt 1)):2174-93 discussion 294-323.

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