Physician Practices

• Diabetes Zone Tool (English/Spanish)(PDF)
• Find a diabetes self-management education (DSME) program near you: https://www.diabetes.org/tools-support/diabetes-education-program
• Healthcare Provider Diabetes Prevention Toolkit: https://amapreventdiabetes.org/
• Provider Telehealth Checklist (PDF)
• 60-Second Type 2 Diabetes Risk Test: https://donations.diabetes.org/site/SPageServer/?pagename=Diabetes_Risk_Test&source=ADA&cate=STAFF&loca=VA&adas=90400
• Self-Care Behaviors to Manage Diabetes: https://www.diabeteseducator.org/living-with-diabetes/Tools-and-Resources
• 2023 Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) Medicare Part B Claims Measure Specification Sheet (PDF)
• A Toolkit to Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings 

• Kidney Disease Zone Tool (English/Spanish) (PDF)
• Attend a no-cost Kidney Smart class to learn more about what causes kidney disease and how patients can help slow its progression. This class is best suited for patients with less than 60% kidney function (Stage 3 to 5, eGFR less than 60) and their caregivers. Find a virtual, telephonic, or in-person class near you: Kidney Smart Patient Flyer (PDF)
• CKD Quick Reference Guide for Primary Clinicians (PDF) 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 (PDF) 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) (PDF)
• Hypertension Control Change Package for Clinicians (PDF): https://millionhearts.hhs.gov/files/HTN_Change_Package.pdf 
• Self-Measured Blood Pressure Monitoring (SMBP):
  • SMBP Action Steps for Clinicians (PDF): https://millionhearts.hhs.gov/files/MH_SMBP_Clinicians.pdf
  • Reimbursement for Hypertension Self-management: SMBP CPT® coding (PDF): https://www.ama-assn.org/system/files/2020-06/smbp-cpt-coding.pdf
• Proper Technique for Accurate Blood Pressure Measurement (PDF)
• 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (PDF): https://www.acc.org/~/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/Guidelines/2017/Guidelines_Made_Simple_2017_HBP.pdf  
• Supporting Your Patients with High Blood Pressure (PDF): https://millionhearts.hhs.gov/files/TipSheet_HCP_Checklist.pdf   
• Atherosclerotic Cardiovascular Disease (ASCVD) Risk Estimator: https://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/
• Clinician Recognition Programs:
  • Target BP Recognition Program: https://targetbp.org/recognition-program/
  • Hypertension Control Challenge: https://millionhearts.hhs.gov/partners-progress/champions/challenge.html
• 2023 Controlling High Blood Pressure Medicare Part B Claims Measure Specification Sheet (PDF)
• A Toolkit to Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings 
• Provider Telehealth Checklist (PDF)
• Cardiac Rehabilitation
  • Cardiac Rehabilitation Is Underused (JPEG) infographic: https://millionhearts.hhs.gov/images/cardiac-rehabilitation-infographic.jpg
  • Cardiac Rehabilitation—An Individualized Program for You (PDF) fact sheet: https://www.aacvpr.org/Portals/0/Docs/AACVPR_CR_Fact_Sheet.pdf
  • Cardiac Rehabilitation Change Package (PDF): https://millionhearts.hhs.gov/files/Cardiac_Rehab_Change_Pkg.pdf

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
  • How Should Physicians and Pharmacists Collaborate to Motivate Health Equity in Underserved Communities? article from the American Medical Association (AMA)
  • 9 ways to reduce inequity in hypertension treatment and control article from the AMA
• A guide to implement the Arthur Kleinman's Eight Questions (PDF) explanatory model
• A checklist to aid in Working Effectively With an Interpreter (PDF)
• Tool to understand and implement the RESPECT model (PDF)
• A checklist (PDF) to ensure effective cross-cultural communication skills
• 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.

• 2024 Traditional MIPS Scoring Guide (PDF)
• 2024 MIPS Overview Quick Start Guide (PDF)
• 2024 MIPS Eligibility and Participation Quick Start Guide (PDF)
• 2024 QPP Final Rule MVP Guide (PDF)
• 2024 MVP Registration Guide (PDF)
• Explore MVPs Available in 2024 
• Are MVPs Right for Me? 

• Physician Business Continuity Plan (PDF)—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 (PDF)