Health Care Homes
Learning Collaborative
Foundations of Health Care Homes Certification - Resources
Health Care Homes
Patient and Family Advisors
- Creating Patient and Family Advisory Councils (IPFCC) (PDF)
- How to Bring Parents on Your Improvement Team: A Step by Step Guide for Staff | Primary Care Collaborative (PCPCC)
- Building Successful Healthcare Patient Advisory Councils (TechTarget)
- How to Create Partnerships with Patients and Families: Advancing the Practice of Patient and Family Centered Care in Primary Care (PCPCC) (PDF)
- Involving Patients and Families on your team: 6 Steps to Creating a Culture of Person and Family Engagement in Health Care (PCPCC) (PDF)
- Partnering with Patients and Families to Enhance Safety and Quality: A Mini Toolkit (IPFCC) (PDF)
- Patient and Family Advisory Council Report (IPFCC) (PDF)
- Working with Patients and Families as Advisors (AHRQ)
- Working with Patient and Families as Advisors Implementation Handbook (AHRQ) (PDF)
Plan Do Study Act Cycle (PDSA)
- How to Improve (IHI)
- Institute of Healthcare Improvement Tools - How to Improve: Science of Improvement Testing Changes (IHI)
- Institute of Healthcare Improvement Tools - Plan-Do-Study-Act (PDSA) Worksheet
- PDSA: Plan-Do-Study-Act (MDH)
- Plan-Do-Study-Act Worksheet, Directions, and Examples (AHRQ)
Practice Improvement Teams
- CHA Practice Improvement Tool (Safety Net) (PDF)
- Creating Patient-centered Team-based Primary Care (AHRQ) (PDF)
- Module 20: Creating Quality Improvement Teams and QI Plans (AHRQ) (PDF)
Quality Improvement Resources
- Administrators, Quality Improvement Professionals, and Organizations | Primary Care Collaborative (PCPCC)
- Creating Capacity for Improvement in Primary Care (AHRQ)
- General QI information (MDH)
- How to Improve (IHI)
- Quality Improvement Essentials Toolkit (IHI) (PDF)
- Quality Improvement Methodology (HRSA)
- Creating a Patient and Family Advisory Council: A Toolkit for Pediatric Practices (NICHQ) (PDF)
Health Care Homes - Communicating with Patients
Health Literacy Resources
- AHRQ Health Literacy Measurement Tools (Revised)
- AHRQ Health Literacy Universal Precautions Toolkit 3rd edition (AHRQ)
Patient Engagement Resources
- 6 Steps to Creating a Culture of Person and Family Engagement in Health Care (PCPCC)
- AHRQ Guide to Patient and Family Engagement in Primary Care
- AHRQ Resources for Engaging Patients and Families in Their Health Care
- Measuring patient engagement: development and Psychometric Properties of the Patient Health Engagement (PHE) Scale (NCBI)
Privacy and Data Security (Stratis Health, UCare)
- Minnesota Government Data Practices Act, Minnesota Statutes, Chapter 13
- Summary of the HIPAA Privacy Rule (HHS)
Race, Ethnicity and Language
Screening Tools and Standardized Assessments
- Implementing Care for Alcohol & Other Drug Use in Medical Settings (NCBH) (PDF)
- Alcohol Use Disorders Identification Test (AUDIT-C) - Viral Hepatitis and Liver Disease (VA)
- Assessment and Action (AAFP)
- OneCare Vermont: Self-Sufficiency Outcome Matrix (CHCS) (PDF)
- Patient Health Questionnaire (PHQ-9 & PHQ-2) (APA)
- The AHC Health-Related Social Needs Screening Tool (CMS) (PDF)
- The Hunger Vital Sign™ (Childrens HealthWatch)
- The PRAPARE Screening Tool - Multiple Languages (NACHC)
- Screening to Brief Intervention (S2BI) (SAMHSA)
Care Team Communication Resources
- Care Coordination Measures Atlas Update - What is Care Coordination? (AHRQ)
- Care Coordination Reducing Care Fragmentation in Primary Care (Safety Net Medical Home Initiative) (PDF)
- Healthy Huddles Information and Tools (Center for Excellence in Primary Care)
Community Integrated Health in Practices
Community Partnerships
Comprehensive Medication Management
Patient and Family Centered Care Self-Assessment Tools Resources
- Guides and Tools (HCH)
- How to Improve: Model for Improvement (IHI)
- Patient Centered Medical Home Assessment (PCMH-A) (PDF)
Planning for Transitions of Care
Referral Tracking
- Care Coordination - Reducing Care Fragmentation in Primary Care (Safety Net Medical Home Initiative) (PDF)
- The Primary Care Team Guide
Shared Decision-Making and Care Planning
- Choosing Wisely: Information and resources to promote conversations between clinicians and patients (ABIM)
- Ottawa Personal Decision Guide, available in multiple languages (Ottawa Hospital and Research Institute)
- Shared Decision-Making (AHRQ)
- The SHARE Approach – a 5-Step Model and Additional Training Resources (AHRQ)
Transition Management
- Connections to Care Transition Help and Local Resources (MN DHS) (PDF)
- Implementation Guide (Safety Net Medical Home Initiative) (PDF)
- Transitions of Care: Technical Series on Safer Primary Care (WHO) (PDF)
Working at Top of License
Action Plans
Evidence-Based Preventive Care Examples
- American Academy of Pediatrics - Patient Care (AAP)
- Institute for Healthcare Improvement - Ask Me 3 (IHI)
- Self-Assessment Tool: National Action Plan to Advance Patient Safety (IHI)
- Recommended Uniform Screening Panel (HRSA)
- Achieving a Shared Plan of Care with Children and Youth with Special Health Care Needs (LPFCH)
- U.S. Preventive Services (CDC)
- Vaccine-Specific Recommendations (CDC)
- Women’s Preventive Services Guidelines (HRSA)
Patient Centered Care Plans
- Achieving a Shared Plan of Care (LPF)
- Engaging Patients in Collaborative Care Plans (AAFP)
- Goals to Care How to Keep the "Person" in Person-Centered (NCQA) (PDF)
- National Institute for Children’s Health Quality - Care Plan Template (NICHQ)
- Pacer Center - Individual Health Care Plans (PC)
- Patient-Centered Care Plans (AHRQ)
Resources
Minnesota Department of Health
Plan Do Study Act Cycle (PDSA)
- How to Improve (IHI)
- Institute of Healthcare Improvement Tools - How to Improve: Science of Improvement Testing Changes (IHI)
- Institute of Healthcare Improvement Tools - Plan-Do-Study-Act (PDSA) Worksheet
- PDSA: Plan-Do-Study-Act (MDH)
- Model for Improvement: Selecting Changes (IHI)
Quality Improvement Resources
- Administrators, Quality Improvement Professionals, and Organizations | Primary Care Collaborative (PCPCC)
- Creating Capacity for Improvement in Primary Care (AHRQ)
- General QI information (MDH)
- How to Improve (IHI)
- Quality Improvement Essentials Toolkit (IHI) (PDF)
- Quality Improvement Methodology (HRSA)
- Tools to Evaluate the Pediatric Patient and Family-Centered Medical Home (AAP) (PDF)
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Last Updated: 08/19/2024