Behavioral Health Bite-Sized Learnings

These short recorded learning modules are on an array of topics related to improving identification of depression and alcohol use disorder in primary care practices and transitioning inpatient psychiatric patients to outpatient care. These were developed by the Quality Innovation Network National Coordinating Center (QIN NCC) in partnership with Dr. Ed Boudreaux, under contract with the Centers for Medicare & Medicaid Services (CMS).

Best Practice Strategies for Health Equity Data Collection

This resource supplements the Health Equity Organization Assessment (HEOA) and offers best practices to address opportunities for improvement from the HEOA results. It is a valuable resource for any organization seeking best practices for improving consistent patient demographic data collection – including REaL (race, ethnicity and language) and SDOH (social determinants of health) – and using the data to identify and address health disparities.

NQIIC Health Equity Roadmap

This resource covers three key areas that should be addressed before beginning any quality improvement or patient safety initiative. It does have a focus on health equity.–/view?usp=sharing

Best Practices from the Field: Using Social Determinants of Health Resource and Referral Data to Increase Equitable Access and Connection Rates to Essential Resources

Prior to COVID-19, health care investments in SDOH programs to support connecting patients to community resources were on the rise, supported by a proliferation of technology solutions like Aunt Bertha, Unite Us, NowPow and others. These resource databases serve as critical tools for tracking the local services landscape and connecting people to the essential resources they need to be healthy (Cartier et al. 2019). However, when adopting these technology solutions to support SDOH programs, it is important to recognize that more resource information does not always result in people being connected to resources. There are best practices for managing resource information, and using and interpreting the data to effectively and equitably connect people to resources. Here, we aim to provide examples to demonstrate the ways in which data usage and interpretation can impact equitable access to essential resources and improve connection rates.

Care Transitions Intervention (CTI) Model

The Care Transitions Intervention® is also known as the CTI® and the Skill Transfer Model®. During a 4-week program, patients with complex care needs and family caregivers receive specific tools and work with a Transitions Coach®, to learn self-management skills that will ensure their needs are met during the transition from hospital to home. This is a low-cost, low-intensity evidence-based intervention comprised of a home visit and three phone calls.

Chronic Kidney Disease (CKD) Screening and Management Mobile Apps

Webpage to access the web-based, Apple App Store, and Google Play versions of the Clinician CKD Screening app and the patient-centered Kidney Choices app. IPRO’s Clinician CKD Screening and Patient-Centered Kidney Choices apps were designed to:
-Help identify CKD early in at-risk patients and to help manage CKD
-To help delay progression
-To provide kidney replacement information for patients whose CKD has progressed to kidney failure.

Chronic Kidney Disease Disparities: Educational Guide for Primary Care

This educational guide is intended to foster the development of primary care practice teams to enhance care for vulnerable patients who are at risk of CKD or who have CKD and are at risk of progression of disease or complications. This guide addresses three aspects of care: identification of CKD; treatment and monitoring progression; and delivering patient-centered care. It is meant to inform readers about disparities in the care of patients with CKD, present potential actions that may improve care and suggest other available resources that may be used by primary care practice teams in caring for vulnerable patients.

CMS Nursing Home Adverse Drug Event Trigger Tool

This tool was developed by CMS for use by nursing home surveyors and is a valuable resource for organizations that are focusing on preventing ADEs.

It was designed to help surveyors identify:

1. The extent to which facilities have identified resident-specific risk factors for adverse drug events

2. The extent to which facilities developed and implemented systems and processes to minimize risks associated with medications that are known to be high-risk and problem-prone

3. When a preventable adverse event has occurred, evaluate if the nursing home identified the issue and responded appropriately to mitigate harm to the individual and prevent recurrence.