Tools

Billing Medicare for Diabetes Self-Management Training
This article describes the conditions that must be met in order for outpatient diabetes self-management training to be reimbursed by Medicare. The article is written by the AAFP's manager for healthcare financing and delivery systems.

National Quality Forum - Endorsed Definition and Framework for Measuring Care Coordination 
This document defines care coordination and provides a fromework for measuring and identifying ways to improve care coordination. Endorsed by the National Quality Forum, the framework provides five different domains and four principles to be used to measure performance.

Assessment of Primary Care Resources and Supports for Chronic Disease Self-Management (PCRS)
This survey, developed by Ed Fisher and colleagues as part of the Robert Wood Johnson Foundation funded Diabetes Initiative, serves to offer providers with an assessment tool to identify ways to improve their self-management programs.  The survey and its recommendations are consistent with the Chronic Care Model and are specifically related to the management of diabetes and other chronic diseases.

Group Visit Starter Kit
The Group Visit Starter Kit, developed by the Improving Chronic Illness Care program in Seattle, Washington, describes the Cooperative Health Care Clinic (CHCC) model developed by Kaiser Colorado staff. Information used to develop the Group Visit Starter Kit came from Collene Hawes of the Group Health Cooperative, Kate Lorig of the Stanford Patient Education Research Center and John Scott of Kaiser-Colorado. Portions of this work first appeared in or are derived or adapted from the Chronic Disease Self-Management Program.

The Group Visit Starter Kit provides information and resources that will help clinicians and others plan and run a group visit for patients with chronic conditions.

How to Conduct a "Walk-About" from the Patient and Family Perspective
Conducting a "walk-about" of a facility with patient and family advisors helps staff gain a perspective of how patients and their families experience care. It is a useful activity to complete before planning and implementing changes related to self-management support in a clinic or other setting. If staff have little experience working with patient and family advisors, conducting a walk-about is a great beginning activity. After the walk-about is completed, use the Wearing New Glasses tool to document ideas for change.

Patients and Families as Advisors: A Checklist for Attitudes
This tool is designed to help clinicians and staff assess their readiness to work with patients and families as advisors to improve services. It can be used in group educational activities as well as by an individual to reflect on practice and attitude.

Wearing New Glasses
Wearing New Glasses is an activity that can be conducted to capture a variety of perspectives from patient and family advisors and staff on ways to improve a clinic or other setting to strengthen patient- and family-centered care and collaborative self-management support. It is helpful to use before planning and implementing changes in combination with a "Walk-About."