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Showing results for "clinical condition or care plan".

1. Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%) (pdf file)
   integrationacademy.ahrq.gov/sites/default/files/2020-07/HbA1c.pdf
   January 01, 2020 - Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%) Comprehensive Diabetes Care: Hemoglobin … or the year prior to the measurement year. … Setting: Ambulatory Care: Clinician Office/Clinic Condition: Endocrine, Endocrine: Diabetes Cross-Cutting … Area: Data Source: Administrative claims, Electronic Clinical Data, Electronic Clinical Data: Laboratory … , Clinician: Individual, Health Plan, Integrated Delivery System Measure Type: Outcome Target Population

2. Comprehensive Diabetes Care: Blood Pressure Control (<140/90 mm Hg) (pdf file)
   integrationacademy.ahrq.gov/sites/default/files/2020-07/Comprehensive_Diabetes_Care_Blood_Pressure.pdf
   January 01, 2020 - Comprehensive Diabetes Care: Blood Pressure Control (<140/90 mm Hg) Comprehensive Diabetes Care: Blood … type 2) during the measurement year or the year prior to the measurement year. … Setting: Ambulatory Care: Clinician Office/Clinic, Pharmacy Condition: Endocrine, Endocrine: Diabetes … Cross-Cutting Area: Data Source: Administrative claims, Electronic Clinical Data: Laboratory, Paper … Medical Records Level of Analysis: Clinician: Group/Practice, Clinician: Individual, Facility, Health Plan

3. Pre-Implementation Planning | The Academy
   integrationacademy.ahrq.gov/products/playbooks/moud-playbook/pre-implementation-planning
   June 02, 2025 - Mid-level managers or clinical staff (e.g., clinical manager, office manager, billing manager) can help … Your community and clinical partners : Just as with any patient with a chronic condition, individuals … intensive services, such as intensive outpatient or residential care, may be necessary. … Whether you can partner with providers who provide care via telehealth or other virtual means : There … such as integrating behavioral health care or medications for OUD.

4. Develop a Shared Care Plan | The Academy
   integrationacademy.ahrq.gov/products/playbooks/behavioral-health-and-primary-care/implementing-plan/develop-shared-care-plan
   August 01, 2025 - Develop a Shared Care Plan The development and use of a patient-centered care plan requires the … A shared care plan can be used as a tool for easy exchange of clinical information, medication reconciliation … A shared care plan may include some or all of the following elements: Team roles and goals—the team members … Engage Patients in Creating Their Care Plan Engaging patients in the creation of their care plan … on developing a shared care plan with children who have chronic or complex health conditions.

5. Establish Protocols to Identify Patients Who Could Benefit From Integrated Care | The Academy
   integrationacademy.ahrq.gov/products/playbooks/behavioral-health-and-primary-care/implementing-plan/establish-protocols
   January 01, 2024 - for timely adjustments to the care plan. … Explore expanding the care team : Explore the option of adding care managers or patient navigators to … Useful Resource(s) for developing workflows and protocols for integrated care Clinical Workflow … Source The Commonwealth Fund Clinical Workflow Plan … patients with multimorbidity involving depression and/or anxiety in primary care.

6. Screening and Diagnosis | The Academy
   integrationacademy.ahrq.gov/products/playbooks/moud-playbook/implementing-treatment/screening-and-diagnosis
   January 01, 2010 - This can be done through clinical discussions or by using a validated screening tool. … For tools requiring staff administration, it may be more efficient to have nurses or clinical assistants … or even refer them to a higher level of care. … or a higher level of care. … Accessed May 29, 2025. https://www.cdc.gov/overdose-prevention/hcp/clinical-care/opioid-use-disorder-diagnosis.html

7. Clinical Outcome Measures | The Academy
   integrationacademy.ahrq.gov/expert-insight/measures
   June 01, 2022 - Clinical health outcomes were used as the primary markers of quality. … The Academy first performed an extensive search for clinical outcome measures that assess the quality … for evaluating quality of integrated care exist. … Measures in the articles either focused on an individual behavioral health condition or the physical … Connect With Us Sign up for Email Updates To sign up for updates or

8. Controlling High Blood Pressure (pdf file)
   integrationacademy.ahrq.gov/sites/default/files/2020-07/Controlling_High_Blood_Pressure.pdf
   January 01, 2020 - Exclusions: Exclude all patients with evidence of end-stage renal disease (ESRD) or kidney transplant … on or prior to the end of the measurement year. … Setting: Ambulatory Care: Clinician Office/Clinic, Ambulatory Care: Urgent Care Condition: Cardiovascular … Cardiovascular: Hypertension Cross-Cutting Area: Data Source: Administrative claims, Electronic Clinical … Data, Paper Medical Records Level of Analysis: Health Plan, Integrated Delivery System Measure Type

9. Fiscal Support for Behavioral Health Services | The Academy
   integrationacademy.ahrq.gov/products/playbooks/behavioral-health-and-primary-care/implementing-plan/secure-financial-support-behavioral-health-services
   August 01, 2025 - Assessment and Care Plan Services 99483   Inter-professional Digital Services 99446-9, 99451, 99452 … covering all services for a defined condition or episode of care. … These metrics can encompass various aspects of care, including clinical outcomes, patient safety, patient … Rocky Mountain Health Plans, a Medicaid managed care plan in Colorado, successfully increased access … the Plan menu.

10. Tracking Patient Outcomes | The Academy
    integrationacademy.ahrq.gov/products/playbooks/opioid-use-disorder/monitor-patient-and-program-progress/tracking-patient-outcomes
    February 01, 2024 - Primary care providers in busy clinical settings may want to use shorter instruments. … her condition. … for referring patients to higher levels of care, either voluntarily or administratively. … Online Self-Assessment Plan To Integrate MAT for OUD in Your Ambulatory Care Setting … Expand Plan To Integrate MAT for OUD in Your Ambulatory Care Setting menu.

11. Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus (pdf file)
    integrationacademy.ahrq.gov/sites/default/files/2020-06/Lexicon.pdf
    January 01, 2020 - plan, making joint follow-up appointments or other collaborative care functions. … Implementing a care plan means: 1. … the care plan. … care plan Identification of need for health behavior change as part of plan for any condition … Adjust care plan quickly for patients who are not improving, whose care doesn’t fit their goals or life

12. Patient-Centered Care Plans | The Academy
    integrationacademy.ahrq.gov/products/playbooks/opioid-use-disorder/implement-mat-for-oud/patient-centered-care-plans
    June 01, 2022 - Develop a Shared Care Plan A care plan is a patient-centered health document designed to facilitate … All care team members should refer to the care plan when managing and treating patients and record any … It can be used as a tool to exchange clinical information, communications, and other forms of coordination … A medication-assisted treatment (MAT) patient’s care plan may include some or all of the following elements … participant in developing and monitoring the care plan.

13. Payment and Reimbursement | The Academy
    integrationacademy.ahrq.gov/products/playbooks/opioid-use-disorder/implement-mat-for-oud/payment-and-reimbursement
    January 01, 2018 - should identify codes for screening and initial assessment; induction; maintenance visits; associated clinical … are often receiving care for a chronic medical condition from the practice or organization. … Unfortunately, such cost-driven strategies may not be consistent with clinical best practices and may … Online Self-Assessment Plan To Integrate MAT for OUD in Your Ambulatory Care Setting … Expand Plan To Integrate MAT for OUD in Your Ambulatory Care Setting menu.

14. Integrated Behavioral Health (IBH) Definition | The Academy
    integrationacademy.ahrq.gov/products/ibh-lexicon/functional-definition
    January 01, 2025 - Clinical functions in place One care team with one plan; not separated physical and mental health … or clinical situations selected for biopsychosocial care Teamwork Clinical functions in … condition, gender, culture or ethnicity, or other identified subset of the population. … and medical care and at what level of severity or priority. 24 This includes clinical conditions, clinical … important to the overall care plan.

15. Chronic Pain Management | The Academy
    integrationacademy.ahrq.gov/products/playbooks/opioid-use-disorder/implement-mat-for-oud/chronic-pain-management
    January 01, 2012 - A comprehensive patient assessment should be conducted to gather information that may help inform clinical … decisions and the treatment plan. … Similarly, depression may interfere with treatment adherence or ongoing management of the patient’s condition … Online Self-Assessment Plan To Integrate MAT for OUD in Your Ambulatory Care Setting … Expand Plan To Integrate MAT for OUD in Your Ambulatory Care Setting menu.

16. Person-Centered Care Plans | The Academy
    integrationacademy.ahrq.gov/products/playbooks/moud-playbook/implementing-treatment/person-centered-care
    January 01, 2025 - Develop a Shared Care Plan A shared care plan is a person-centered health document designed to … Every professional who is part of the patient's care should be familiar with the patient's care plan. … A patient's care plan for OUD treatment may include some or all the following elements: Goals: Includes … Every professional who is part of the patient's care should be familiar with the patient's care plan. … Addiction Science & Clinical Practice . 2025;20(1):22. doi:10.1186/s13722-025-00555-0

17. Developing an Implementation Plan | The Academy
    integrationacademy.ahrq.gov/products/playbooks/opioid-use-disorder/plan-integrate-mat-for-oud/developing-implementation-plan
    June 01, 2022 - , organizations, or health systems. … Identify Clinical Champions and the Implementation Planning Team Identify clinical champions of … How will you define the clinical care team?   … Online Self-Assessment Plan To Integrate MAT for OUD in Your Ambulatory Care Setting … Expand Plan To Integrate MAT for OUD in Your Ambulatory Care Setting menu.

18. Treatment Approaches | The Academy
    integrationacademy.ahrq.gov/products/playbooks/opioid-use-disorder/implement-mat-for-oud/treatment-approaches
    January 01, 2020 - Then they should follow clinical guidance regarding the treatment and care of pregnant and postpartum … the care her or she needs. 8 Because of the potential delays in care, providers in rural areas should … materials, talking points, or strategies for the patient to use with others when discussing their condition … Online Self-Assessment Plan To Integrate MAT for OUD in Your Ambulatory Care Setting … Expand Plan To Integrate MAT for OUD in Your Ambulatory Care Setting menu.

19. How Do IBH Practices & Functions Differ? | The Academy
    integrationacademy.ahrq.gov/products/ibh-lexicon/practice-differences
    July 01, 2024 - Clinical functions in place One care team with one plan; not separated physical and mental health … or clinical situations selected for biopsychosocial care Teamwork Clinical functions in … of shared working environment or “space” Type of clinical collaboration A systemic clinical … This appears as a difference between practices, but does not require it as a condition to be defined … test of effectiveness with a limited number of patients or clinical scope.

20. Tracking Patient Outcomes | The Academy
    integrationacademy.ahrq.gov/products/playbooks/moud-playbook/monitor-patient-outcomes/tracking-patient-outcomes
    May 29, 2025 - or results of treatment — is standard of care for primary care providers regardless of how notes are … conduct clinical research. … for practices that conduct clinical research. … for practices that conduct clinical research. … a patient from treatment, but rather as a call to revise the individualized shared care plan.