Author: IPRO

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.

Hospital based care transition model that coordinates the patient’s discharge plan throughout the hospitalization and then provides a post-acute discharge guide and follow-up telephone calls.

A resource for people with physical disabilities that helps them understand their rights for access to the same medical services as everyone else.

Interactive mapping tool to identify health disparities between subgroups of Medicare beneficiaries. The tool presents health-related measures from Medicare claims by sex, age, dual eligibility for Medicare and Medicaid, race and ethnicity, and state and county.

Effective communication is critical to ensuring understanding, empowering patients, and providing high quality care. A language access plan can help ensure that an organization provides high quality and appropriate language services. This guide identifies ways that providers can assess their programs and develop language access plans to ensure persons with limited English proficiency have meaningful access to their programs.

The Disparities Impact Statement, developed by the CMS Office of Minority Health, helps organizations to identify, prioritize, and take action on health disparities. The tool walks users through a four-step process to identify and address disparities:

Step 1: Identify vulnerable populations and their disparities
Step 2: Set SMART aims (Specific, Measurable, Attainable, Relevant, Time-based)
Step 3: Develop an Action Plan
Step 4: Monitor, improve and disseminate

The Disparities Impact Statement includes fillable worksheets for each step that can be saved and edited. The CMS Office of Minority Health offers free assistance from their Health Equity Technical Assistance Team if needed.

Get an overview of key issues related to readmissions for racially and ethnically diverse Medicare beneficiaries, as well as useful resources for hospital leaders to take action to address readmission.

This guide equips clinicians with information for treating chronic pain in adults living with a history of substance use. The guide discusses chronic pain management, including treatment with opioids. It also includes information about substance use assessments and referrals. Available at no cost from SAMSHA.

Order from SAMHSA directly, no cost. PDF available online.

Available at no cost from SAMSHA. EBP for MAT in general medical settings for patients with OUD (includes assessment tools, guidelines, etc.) Collect data on success rates using various MAT through transitions of care, treatment in single settings, etc.

A list of suggested pain management items that should be communicated to the next provider upon discharge. A way to engage a care transition community, identify communication elements needed for electronic health record modification, or provide an additional tool to improve med reconciliation.

Read the article “Pain management-related assessment and communication across the care continuum: Consensus of the opioid task force of the island peer review organization pain management coalition” published in the Journal of the American College of Clinical Pharmacy.

This is designed for use in any facility by staff or a healthcare provider. Improvement of cross-setting management of pain management during transitions of care to prevent adverse drug events and subsequently reduce emergency department visits, hospitalizations, and readmissions.

This is designed for nursing home staff, and other facilities could use it as well. It has information about ADEs including: definition, facts, common ADEs, and occurrences that could point to an ADE.