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Population Identification Processes act as a starting point for an integrated approach to healthcare by providing a standardized way to identify and stratify chronic disease patient populations.
Evidence-Based Practice Guidelines provide a road map for implementing evidence-based practices into workflows to improve outcomes for patients with chronic diseases.
Coaching and Collaborative Practice Models offer ways to implement a team-based care approach to improve the engagement and overall management of patient populations with chronic diseases.
Patient Self-Management Education enables and empowers patients to better self-manage their chronic disease. Validated processes to improve self-management can be integrated into practice workflows, including:
- Patient Activation Assessments
- Patient Outcomes Support (Education)
- Patient/Provider Engagement Through Motivational Interviewing
Care Coordination between providers (ie, specialists and primary care), institutions (ie, hospital and community-based providers), and care teams (ie, providers and patients) is a critical component to ensure a standardized approach to patient management, close existing gaps, and improve outcomes.
Monitoring/Process and Outcomes Measurement provides a simple yet comprehensive repository of the key policy decisions, marketplace trends, and best practices that will increase understanding and application of quality-improvement measures in the practice setting.