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221. Patient Self-Management Support Programs: An Evaluation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/ptmgmt/ptmgmt.pdf
     November 01, 2007 - HbA1c values - BP values - LDL values - HDL levels - Random blood glucose - Weight - BMI … , as advocated by many proponents of the chronic care model, then health risk assessments or other screening … devices were provided (such as glucometers, peak flow meters, digital weight scales, or home cholesterol screening … primary care visits per patient per year, and HEDIS scores for HbA1c tests and lipid, eye, and kidney screenings

222. Developing and Assessing the Validity of Claims-based Indicators of Frailty & Functional Disabilities in Electronic Health Records (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/learning-health-systems/frailty-ehr.pdf
     September 01, 2022 - Screening tools for frailty may identify individuals in need of further evaluation at the point of … Frailty screening using the electronic health record within a Medicare accountable care organization … Enhancing the prediction of healthcare costs and utilization by including outpatient BMI values to