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Total Results: 354 records

Showing results for "improving clinical-community linkages in primary care for patients with multiple chronic conditions".

101. Electronic Records to Improve Care for Children - 2009 | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/electronic-records-improve-care-children/annual-summary/2009
     January 01, 2009 - A shared, community-wide electronic health record (EHR) for health care providers in pediatric primary … in quality of care for children with asthma. … Specific Aims Implement a shared, community-wide EHR for health care providers in pediatric primary … patients with persistent asthma. … Dropping the baton during the handoff from emergency department to primary care.

102. Community Connections: Linking Primary Care Patients to Local Resources for Better Management of Obesity (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/obesity-toolkit.pdf
     March 01, 2014 - Community Connections: Linking Primary Care Patients to Local Resources for Better Management of Obesity … Community Connections Linking Primary Care Patients to Local Resources for Better Management … partner as akin to a patient searching for a new primary care physician. … Maintaining Contact with the Community Partner Community Connections: Linking Primary Care Patients … The Improving Efficiency in Primary Care toolkit (http://fammed.ucdenver.edu/efficiency/default.htm)

103. Using Health IT to Improve Care Coordination and Outcomes in Patients with Complex Health Care Needs (pdf file)
     digital.ahrq.gov/sites/default/files/docs/coordination-patients-complex-needs-slides-022014.pdf
     February 20, 2014 - education/information • Nurses: Patient callbacks ► High-risk patients 10 Primary Care Provider … Notification 11 Primary Care Provider Notification (continued) 12 Electronic Health Record … Feldman, P.I. 50 Improving Care Transitions for Complex Patients Through Decision Support Eric … Patients with Complex Health Care Needs Moderator and Presenters�Disclosures Improving Care Transitions … Acknowledgments (continued) Improving Care Transitions for Complex Patients Through Decision Support

104. Develop a Shared Care Plan | The Academy
     integrationacademy.ahrq.gov/products/playbooks/behavioral-health-and-primary-care/implementing-plan/develop-shared-care-plan
     July 01, 2024 - Playbooks Integrating Behavioral Health and Primary Care Playbook … In addition, patient engagement through shared care plans promotes shared decisionmaking between patients … Format Other Source Patient Centered Primary Care Institute … Source AHRQ Lexicon for Behavioral Health and Primary Care Integration (page 18) File … Source AHRQ Lexicon for Behavioral Health and Primary Care Integration (page 19) File

105. Building State Cooperatives for Healthcare Improvement: Meeting Summary (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/building-state-cooperatives-meeting-summary.pdf
     September 26, 2024 - Alabama Primary Health Care Association (APHCA) as key partners. … the primary care safety net grounded in a robust patient and stakeholder engagement infrastructure. … of care, and health outcomes for people in medically underserved areas with multiple chronic conditions … on expanding primary care team capacity to manage cardiovascular disease in Medicaid patients. … improving quality of care and patient outcomes.

106. R18Hs017203-Gurwitz-Final-Report-2011 (pdf file)
     digital.ahrq.gov/sites/default/files/docs/publication/r18hs017203-gurwitz-final-report-2011.pdf
     January 01, 2011 - We developed an automated system to facilitate the flow of information to primary care providers. … The primary care physician was only notified of new prescription medications that the patient filled … the primary care physician following a discharge from the hospital. … Improving primary care for patients with chronic illness. JAMA. Oct 9 2002;288(14):1775-1779. 2. … We developed an automated system to facilitate the flow of information to primary care providers.

107. Primary Care and Patient Safety: Opportunities at the Interface | PSNet
     psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
     September 28, 2022 - primary care providers prescribe medications for patients with substance use disorders. … AHRQ Resources That Support Safety in Primary Care Guide to Improving Patient Safety in Primary Care … majority of patients had not had primary care for some time. … We can then partner with our patients to engage them in improving quality, and quality metrics, because … testing algorithm for patients in primary care practices.

108. How Do IBH Practices & Functions Differ? | The Academy
     integrationacademy.ahrq.gov/products/ibh-lexicon/practice-differences
     July 01, 2024 - — The basic functions for integrated behavioral health in context of primary care: Triage—identification … Patient may often need to move between separate primary care to behavioral health office or telehealth … visits to improve clinical outcomes in adults with mental health conditions and those attending primary … help in connecting with clients for whom their services were designed. b … The effectiveness of teleconsultations in primary care: systematic review.

109. Case Example #5: WellMed | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/tools/workforce-financing/case-example-5.html
     July 01, 2019 - primary care workforce, and conducted site visits to primary care practices with innovative workforce … It aspires to “one-stop shopping” for patients, bringing in-house specialists to the primary care clinics … Registered nurse (RN) outpatient case managers oversee the management of high-risk patients with multiple … chronic conditions based on their risk stratification scores. … Primary care team members feel responsible for improving metrics, so improvement strategies are addressed

110. Case Example #3: Fairview Health Services | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/tools/workforce-financing/case-example-3.html
     July 01, 2019 - primary care workforce, and conducted site visits to primary care practices with innovative workforce … Return to Contents Implications for Primary Care Staffing Models Well-defined roles and respect for … Fairview is an exemplar primary care practice in its utilization of MTM to address and improve patients … Fairview Pharmacy Services, for hosting a site visit for the AHRQ New Models of Primary Care Workforce … Best Practices: Improving Patient Outcomes and Costs in an ACO Through Comprehensive Medication Therapy

111. Developing and Sustaining State-Based Infrastructure To Support Primary Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/projects/state/how-to-guide/how-to-guide.pdf
     August 01, 2024 - For example: » Alabama Cardiovascular Cooperative partnered with the Alabama Primary Health Care … Patient- and Family-Centered Care) Foundations and private donors investing in improving health/health-related … technical assistance and education to primary care practices and other health system partners on improving … fund a primary care extension program housed in a state university for services that benefit patients … Interview with James Mold from Oklahoma Primary Healthcare Improvement Cooperative. 2022. 44.

112. Cloud Care: A Feasibility Study of Cloud-Based Care Plans for Children With Medical Complexity | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/cloud-care-feasibility-study-cloud-based-care-plans-children-medical-complexity
     January 01, 2024 - Cloud Care: A Feasibility Study of Cloud-Based Care Plans for Children With Medical Complexity … children with medical complexity is feasible to implement and may improve care coordination for children … with medical complexity, providing the foundation for a future digital health intervention to address … Project Name: Cloud Care: A Feasibility Study of Cloud-Based Care Plans for Children With Medical Complexity … Cloud Care: A Feasibility Study of Cloud-Based Care Plans for Children with Medical Complexity - Final

113. New Models of Primary Care Workforce - Case Example #5: WellMed (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/workforce-financing/case_example_5.pdf
     October 01, 2016 - It aspires to “one-stop shopping” for patients, bringing in-house specialists to the primary care clinics … Registered nurse (RN) outpatient case managers oversee the management of high-risk patients with multiple … chronic conditions based on their risk stratification scores. … Complex care followup is traditionally for 90 days before the patient is returned to the primary care … Primary care team members feel responsible for improving metrics, so improvement strategies are addressed

114. Recommendation: Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Cardiovascular Disease Risk Factors: Behavioral Counseling Interventions | United States Preventive Services Taskforce
     www.uspreventiveservicestaskforce.org/uspstf/recommendation/healthy-lifestyle-and-physical-activity-for-cvd-prevention-adults-without-known-risk-factors-behavioral-counseling
     July 26, 2022 - general guidance to assist primary care settings with linking patients to nonmedical support ( https … care linkages needed to implement this recommendation. … Primary care–feasible interventions with strong linkages between clinical and community settings may … of key challenges for primary care. … Physical activity: brief advice for adults in primary care: public health guideline [PH44].

115. New Models of Primary Care Workforce and Financing - Case Example #3: Fairview Health Services (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/workforce-financing/case_example_3.pdf
     October 01, 2016 - primary care workforce, and conducted site visits to primary care practices with innovative workforce … Patient Population Description and Practice Panel Size In 2014, Edina cared for 12,184 unique patients … Community Linkages The Edina clinic works closely with the Alzheimer’s Association to provide additional … Fairview is an exemplar primary care practice in its utilization of MTM to address and improve patients … Best Practices: Improving Patient Outcomes and Costs in an ACO Through Comprehensive Medication Therapy

116. Findings | Agency for Healthcare Research and Quality
     www.ahrq.gov/data/apcd/envscan/findings.html
     July 01, 2022 - mellitus is often an interdisciplinary effort in a patient-centered medical home, involving primary care … care physicians Primary care physician (PCP) metrics may need to be different from more discrete episodes … Measuring episodes of care for patients with multiple chronic diseases. … For patients with multiple chronic diseases, defining which “episode of care” to use may be difficult … patients with multiple chronic conditions.

117. THE HCUP NATIONWIDE READMISSIONS DATABASE (NRD), 2013
     hcup-us.ahrq.gov/db/nation/nrd/NRD_Introduction_2013.jsp
     January 01, 2013 - The database includes discharges for patients with and without repeat hospital visits in a year and those … from patients with an age of 0 from SID with verified patient linkage numbers on less than 90 percent … With a file of this size and without careful planning, space could easily become a problem in a multi-step … release of discharge records for patients with HIV diagnoses. … all diagnoses DXMCCS1 Multi-level CCS category for principal diagnosis E_MCCS1 Multi-level

118. Evidence Summary: Food Insecurity: Screening | United States Preventive Services Taskforce
     www.uspreventiveservicestaskforce.org/uspstf/document/evidence-summary/food-insecurity-screening
     March 11, 2025 - services for food insecurity in primary care settings. … food insecurity in primary care was very limited. … Food insecurity is associated with multiple chronic conditions and physical health status among older … primary care. … adult primary care.

119. THE HCUP NATIONWIDE READMISSIONS DATABASE (NRD), 2014
     hcup-us.ahrq.gov/db/nation/nrd/NRD_Introduction_2010-2014.jsp
     January 01, 2014 - The database includes discharges for patients with and without repeat hospital visits in a year and those … from patients with an age of 0 from SID with verified patient linkage numbers on less than 90 percent … With a file of this size and without careful planning, space could easily become a problem in a multi-step … release of discharge records for patients with HIV diagnoses. … Multi-level CCS category for principal diagnosis E_MCCS1 Multi-level CCS category for first-listed

120. Behavioral Counseling Research and Evidence-Based Practice Recommendations: U.S. Preventive Services Task Force Perspectives | United States Preventive Services Taskforce
     www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/behavioral-counseling-research-and-evidence-based-practice-recommendations-us-preventive-services-task-force-perspectives
     March 01, 2014 - Integration of behavioral counseling interventions with primary care delivery increases the reach of … interventions in primary care and for estimating the certainty and magnitude of the net benefit of these … patients with risky or harmful patterns of alcohol use. … Theories and intervention approaches to health-behavior change in primary care. … Possible Definitions of Intensity for Primary Care–Feasible and Primary Care–Referable Interventions