Physician Practices

• Diabetes Zone Tool (English/Spanish) 
• Find a Diabetes Self-Management Education (DSME) Program
• Healthcare Provider Diabetes Prevention Toolkit
• Provider Telehealth Checklist
• 60-Second Type 2 Diabetes Risk Test
• Self-Care Behaviors to Manage Diabetes
• A Toolkit to Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings 

• Kidney Disease Zone Tool (English/Spanish)
• CKD Quick Reference Guide for Primary Clinicians from the National Kidney Foundation (NKF)
• Clinical practice guideline for Cardiovascular Disease and CKD from Kidney.org
• Clinical practice guideline for Diabetes and CKD from Kidney.org
• Optimal Care for Kidney Health MIPS Value Pathway from CMS
• Just Diagnosed With CKD for Patients from the American Kidney Fund (AKF)
• CKD Frequently Asked Questions from NKF and the American Society for Clinical Pathology (ASCP)
• Eating Right for CKD from National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

• Heart Disease Zone Tool (English/Spanish) 
• Hypertension Control Change Package for Clinicians
• Self-Measured Blood Pressure Monitoring (SMBP):
  • SMBP Action Steps for Clinicians
  • Reimbursement for Hypertension Self-management: SMBP CPT® coding
• Proper Technique for Accurate Blood Pressure Measurement
• 2025 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
• Supporting Your Patients with High Blood Pressure
• Clinician Recognition Programs:
  • Target BP Recognition Program
  • Hypertension Control Challenge
• 2023 Controlling High Blood Pressure Medicare Part B Claims Measure Specification Sheet
• A Toolkit to Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings 
• Provider Telehealth Checklist

Assess social determinants of health (SDOH) 

Review the Centers for Disease Control and Prevention (CDC) short videos on health equity and SDOH for an overview of these topics.

Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) is a national standardized patient risk assessment tool designed to engage patients in assessing and addressing SDOH.

• Review the PRAPARE Implementation and Action Toolkit to understand how to gather, assess, and respond to SDOH data.
• Use the PRAPARE Readiness Assessment Tool to evaluate your organization's readiness to support your health center members in implementing PRAPARE and using PRAPARE data.
• Use the PRAPARE Screening Tool to collect and assess patient SDOH data. This tool includes 17 core questions and 4 optional questions about SDOH. Its toolkit includes the four electronic health record (EHR) tools, technical resources, best practices, multiple tested workflows, and other resources. This screening tool is available in 33 languages.
• Use this guide from the Centers for Mediacre & Medicaid Services (CMS) to improve the collection of SDOH data with ICD-10-CM Z codes.

Address SDOH

Provide culturally and linguistically appropriate services (CLAS) by using these tools:

• A how-to guide on Providing CLAS (PDF) —This handout from the U.S. Department of Health & Human Services Office of Minority Health gives clear instructions on communication, health literacy, using teach back, language assistance, applying the LEARN model, strategies for listening/learning, and partnership building.
  • The teach-back method will confirm if you successfully applied CLAS:
    • Review HSAG Teach-back Tools to implement in your practice.
    • Reminder to Use Teach-Back posters (PDF) help providers check and practice skill development
  • 9 ways to reduce inequity in hypertension treatment and control article from the AMA
• Neighborhood Navigator from the American Academy of Family Physicians is an interactive tool to connect patients with supportive resources in their neighborhood. Look up by ZIP Code.

• Traditional Merit-based Incentive Payment Systems (MIPS) Overview
• 2025 MIPS Quick Start Guide for Small Practices
• Explore MIPS Value Pathways (MVPs)
• 2025 MVP Registration Guide

• Physician Business Continuity Plan—The Business Continuity Plan (BCP) is a living document that comprises resources, policies, and procedures to be used in the event of a disaster or major disruption of operations. The BCP is one way to help practices limit disruption to crucial patient care services, where applicable, and minimize adverse economic impact by resuming normal operations as quickly as possible.
• Centers for Disease Control and Prevention (CDC) Emergency Action Plan