CCM Implementation Tools Indexed by Element

We've linked materials that appear in the “Integrating Chronic Care and Business Strategies in the Safety Net” Toolkit to each of the six elements of the Chronic Care Model.  To access these resources, select an element within the Model graphic, or scroll to the lists below and select by name.


The Chronic Care Model
Community Health Systems Self- Management Support Delivery System Design Design Support Clinical Information Systems
ALL ELEMENTS
Patient Assessment of Chronic Illness Care (survey) [.doc]
Patient Assessment of Chronic Illness Care Scoring Guide (guide) [.doc]
Assessment of Chronic Illness Care (survey) [.pdf]
Assessment of Chronic Illness Care Scoring Guide (guide) [.pdf]
Quantitative Monthly Diabetes Report Template (worksheet) [.xls]
Narrative Monthly Report Template (worksheet) [.doc]
Project Planning Form (worksheet) [.doc]
Primary Care Practice High Level Flowchart (worksheet) [.doc]
Plan-Do-Study-Act Worksheet (worksheet) [.doc]
Plan-Do-Study-Act Self Management Support Example (guide) [.ppt]
Huddle Sheet (worksheet) [.doc]
Change Flow Chart (guide) [.ppt]
How Hot Are Your Improvement Action Plans PDSAs (worksheet) [.doc]
Pay for Performance: An Introduction (guide) [.doc]
Pay for Performance: A Decision Guide for Purchasers (guide)  [.pdf]
The CAHPS® Improvement Guide (guide) [.pdf]
Redesign and Finance Change Package (guide) [.pdf]

COMMUNITY
Building Your Community (guide on external Web site)
Diabetes Initiative (external Web site)
Community (presentation) [.ppt]

HEALTH SYSTEMS
Forming the Team (guide) [.doc]
Seven Leadership Leverage Points (white paper) [.pdf]
Zen of Teams (presentation) [.ppt]
Chronic Care Model Primer (guide) [.doc]
A Model for Accelerating Improvement (guide) [.pdf]
Going Lean in Health Care (white paper) [.pdf]
CAHPS Adult Primary Care Survey (survey) [.doc]
Primary Care Practice Know Your Processes (survey) [.doc]
Finance Collaborative Pre-work (survey) [.xls]
Redesign and Finance Measures (guide) [.pdf]
Executive Review of Improvement Projects (white paper) [.doc]
Panels and Panel Equity (guide) [.pdf]
Practice Supply Worksheet (worksheet) [.doc]
Daily Demand (guide) [.doc]
Front Desk Collections Flow Chart (guide) [.pdf]
Getting Paid - Maximizing Collections (presentation) [.pdf]
Group Visit Financials (worksheet) [.xls]

SELF MANAGEMENT SUPPORT
Shared Care Plan (patient material) [.pdf]
Health Literacy A Manual for Clinicians (guide on external Web site) 
Helping Patients Manage Their Chronic Conditions (report on external Web site)
Depression Management Tool Kit (guide on external Web site)
Open Access - Open Office (patient material) [.doc]
Action Plan (guide) [.doc]
Agenda Setting Tool: Bubble Diagram (patient material) [.ppt]
World Education (external Web site)
Diabetes Initiative (external Web site)
5 A’s Behavior Change Model (guide) [.pdf]

DELIVERY SYSTEM DESIGN
Primary Care Staff Satisfaction Survey [.doc]
Primary Care Practice Know Your Processes (survey) [.doc]
High functioning clinical teams are extremely efficient (presentation) [.ppt]
Converting Guidelines to Practice (guide) [.doc]
Cross Train Staff (guide) [.doc]
Team Effectiveness Exercise (survey) [.doc]
Depression Management Tool Kit (guide on external Web site)
Spanish PHQ-9 (survey on external Web site)
Organizing the Planned Visit (guide) [.doc]
System Changes and Interventions: Planned Care (presentation) [.ppt]
Group Visit Starter Kit (guide) [.doc]

DECISION SUPPORT
National Disease Guidelines (external Web site)
National Voluntary Consensus Standards for Ambulatory Care (measures on external Web site)
Converting Guidelines to Practice (guide) [.doc]
Depression Management Tool Kit (guide on external Web site)
Diabetes Standing Orders (worksheet) [.doc]

CLINICAL INFORMATION SYSTEMS
Chronic Disease Registries: A Product Review (guide on external Web site)
CDEMS registry (external Web site)