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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool9_trans_care.docx
July 28, 2016 - Tool 9: Transitional Care Planning
Tool 9: Whole-Person Transitional Care Planning Tool
Purpose
The social, economic, and geographic conditions in which individuals live have a profound impact on individuals’ health status. Efforts to reduce readmissions by optimizing self-management or long-term health status will …
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/demostates/mdstateataglance.pdf
March 01, 2012 - Maryland State at a Glance
…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/demostates/wystateataglance.pdf
March 01, 2012 - In addition, Wyoming is
utilizing telehealth services with providers to support behavior/mental health
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb6.html
February 01, 2023 - Interventions
For changes in psychotropic meds:
__ Monitor and report changes in anxiety, sleep patterns, behavior … , or mood
__ Monitor and report drug side effects
__ Behavior management strategies
__ … _______________________________
Risk Factor: Orthostatic Hypotension
Risk Factor: Unsafe Behavior … hydration
__ TED hose
__ Other: _________________________________
Selected Interventions
__ Behavior
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www.ahrq.gov/priority-populations/observances/hispanic-heritage/index.html
October 01, 2021 - Grantees Focusing on Hispanic and Latino Populations
Peter Yellowlees, M.D.
“I have found it fascinating to see the way that almost all patients speak differently, using simpler phrases and less words, when using an interpreter. Their descriptions of clinical symptoms and histories is much ric…
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www.ahrq.gov/evidencenow/model/profiles/walkers-point.html
March 01, 2021 - "If we can find ways to focus consistently on behavior change and support people in finding success with … Clinicians will bring up behavior changes that will make patients feel good that very day—and helping … If we can find ways to focus consistently on behavior change and support people in finding success with … His team is focused on finding new ways to encourage behavior change so that preventive care yields long-term
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www.ahrq.gov/ncepcr/tools/workforce-financing/exec-summary.html
July 01, 2019 - For patients with diabetes in a pilot program, the CHWs help with health behavior change and goal setting
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www.ahrq.gov/cpi/centers/cepi/dpi.html
February 01, 2025 - The Division of Practice Improvement
The Division of Practice Improvement (DPI), part of the Center for Evidence and Practice Improvement , promotes innovative and evidence-based healthcare and advances the science of dissemination and implementation DPI creates materials to teach healthcare professionals and…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/aspire_webinar3/aspire_webinar3.pptx
December 01, 2014 - Designing & Delivering Whole-Person Transitional Care The Hospital Guide to Reducing Medicaid Readmissions Webinar 3
Designing & Delivering Whole-Person Transitional Care
The Hospital Guide to Reducing Medicaid Readmissions
Webinar 3: Review & Update Readmission Reduction Efforts
Agenda
Describe the purpose of co…
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www.ahrq.gov/policymakers/chipra/pubs/background-2012/backgrndapb.html
December 01, 2012 - Bypass
Improved Core Set
Improved Core Set
Screening +/- Followup
Development and Behavior … Whether health care providers address parental concerns about their child's learning, development, and behavior
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/workforce-financing/case_example_6.pdf
October 01, 2016 - New Models of Primary Care Workforce - Case Example #6: Henry Ford Health System
New Models of Primary Care
Workforce and Financing
Case
Example Henry Ford Health System6
New Models of Primary Care Workforce
and Financing
Case Example #6: Henry Ford Health System
Prepared for:…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/workforce-financing/workforce-executive-summary.pdf
October 01, 2016 - For patients with diabetes in a pilot program, the
CHWs help with health behavior change and goal setting
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www.ahrq.gov/sites/default/files/publications/files/workforce_executive_summary_0.pdf
October 01, 2016 - For patients with diabetes in a pilot program, the
CHWs help with health behavior change and goal setting
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/apcfigtxt8.html
December 01, 2017 - Interventions
For changes in psychotropic meds:
_X_ Monitor and report changes in anxiety, sleep patterns, behavior … , or mood
___ Monitor and report drug side effects
_X_ Behavior management strategies
… _______________________________
Risk Factor: Orthostatic Hypotension
Risk Factor: Unsafe Behavior … ___ TED hose
___ Other: _________________________________
Selected Interventions
_X_ Behavior
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Galt.pdf
January 01, 2004 - Attitude is a person’s positive or negative feelings about
performing the target behavior. … the
behavior multiplied by the evaluation of those consequences. … Although these two theoretical models have made significant contributions
toward behavior theory, TAM … Belief, attitude, intention and
behavior: an introduction to theory and research. … Understanding attitudes and
predicting social behavior.
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www.ahrq.gov/sites/default/files/wysiwyg/cpi/about/organization/nac/interim-pcortf-snac-report.pdf
October 01, 2022 - broad array of
services for mental health conditions, substance use disorders, and health-related
behaviors … provider payment
policy and its intersection with health disparities, quality performance, provider behavior … transformation that supports a more holistic approach to
health and well-being and health-related behavior
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www.ahrq.gov/ncepcr/tools/workforce-financing/case-example-6.html
July 01, 2019 - Case Example #6: Henry Ford Health System
This report is based on research conducted by Abt Associates in partnership with the MacColl Center for Health Care Innovation and Bailit Health Purchasing, Cambridge, MA, under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD…
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/implementation-guides/implementation-guide2/implguide2appb.html
September 01, 2014 - Designing Care Management Entities for Youth with Complex Behavioral Health Needs
Appendix B: Key CME Design Features in CHIPRA Quality Demonstration States, as of June 2014
Previous Page
Table of Contents
Designing Care Management Entities for Youth with Complex Behavioral Health Needs
Part 1: …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Cotayo.pdf
April 22, 2004 - definition, patients who meet the
criteria for medically necessary inpatient care exhibit symptoms or behaviors … To reduce these behaviors also mitigates considerable safety risk. … percent of admissions, were
high acuity cases, like highly lethal suicide attempt; self-defeating behavior … Psychiatric Association: Practice guideline
for the assessment and treatment of patients with
suicidal behaviors
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool13_ed_care_plan.docx
May 01, 2015 - Tool 13: ED Care Plan
Tool 13: ED Care Plan
Purpose
The purpose of the emergency department (ED) care plan is to create institutional memory across numerous providers; make easily visible prior recurrent presentations and related testing; identify a patient’s existing clinical, behavioral, and social services; and …