Preventing Chronic Diseases Action Plan - Recommended Evidence-based programs, policies and practices

Focus area 1 - Reduce Obesity in Children and Adults

• Goal #1.1: Create community environments that promote and support healthy food and beverage choices and physical activity.
• Goal #1.2: Prevent childhood obesity through early child-care and schools.
• Goal #1.3: Expand the role of health care and health service providers and insurers in obesity prevention.
• Goal #1.4: Expand the role of public and private employers in obesity prevention.

Focus area 2 - Reduce Illness, Disability and Death Related to Tobacco Use and Secondhand Smoke Exposure

• Goal #2.1: Prevent initiation of tobacco use by New York youth and young adults, especially among low socioeconomic status (SES) populations.
• Goal #2.2: Promote tobacco use cessation, especially among low SES populations and those with poor mental health.
• Goal #2.3: Eliminate exposure to secondhand smoke.

Focus Area 3: Increase Access to High Quality Chronic Disease Preventive Care and Management in Both Clinical and Community Settings

• Goal #3.1: Increase screening rates for cardiovascular disease, diabetes and breast, cervical and colorectal cancers, especially among disparate populations.
• Goal #3.2: Promote evidence-based care
• Goal #3.3: Promote culturally relevant chronic disease self-management education.

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Focus area 1 - Reduce Obesity in Children and Adults

Goal #1.1 (Action Plan) (Dashboard): Create community environments that promote and support healthy food and beverage choices and physical activity.

1. Adequately invest in proven community-based programs that result in increased levels of physical activity and improved nutrition.
   1. Fact Sheet: Promoting Nutrition Standards For Healthy Food and Beverage Procurement
      Identifies actions and resources to help worksites, municipal agencies, child care centers, group homes, community-based organizations, and other institutions adopt improved nutrition standards through food procurement, advocacy, and other strategies.
   2. Fact Sheet: Promoting Complete Streets
      Describes steps municipalities can take to create, implement or enhance Complete Streets policies.
   3. NYS Department of Transportation — Complete Streets
   4. CDC Vital Signs on Physical Activity and Disability
      Adults with disabilities who get no physical activity are 50% more likely to have certain chronic diseases than those who get the recommended amount of physical activity. This Vital Signs toolkit promotes physical activity among adults with disability. The toolkit includes a Morbidity and Mortality Weekly Report, fact sheet with key messages and calls to action, digital press release, online videos and podcasts. Additional resources and strategies (Increasing Physical Activity among Adults with Disabilities) are also provided by CDC.
2. Increase retail availability of affordable healthy foods that meet the needs of communities, especially those with limited access to nutritious foods.
   1. Healthy Food Acess Portal
      Resource for increasing access to healthy food
      
   2. Licensing Healthy Food Retailers
      Describes a model licensing ordinance for healthy food retailers. Training, resources, analysis to support healthy environments.
3. Adopt policies and implement practices to reduce overconsumption of sugary drinks.
   1. Sugar-Sweetened Beverages Playbook
      Provides resources for advocates and policy makers who want to address the availability of sugary beverages to children in their communities.
4. Adopt policies and implement practices to increase access to affordable healthy foods for individuals living in group homes or adult homes for people with disabilities.
   1. Fact Sheet: Promoting Nutrition Standards For Healthy Food and Beverage Procurement
      Identifies actions and resources to help worksites, municipal agencies, child care centers, group homes, community-based organizations, and other institutions adopt improved nutrition standards through food procurement, advocacy, and other strategies.
5. Establish joint use agreements to open public areas and facilities for safe physical activity.
   1. Joint Use Agreements
      Helps school staff and other community leaders craft and implement joint use agreements.
6. Adopt, strengthen and implement local policies and guidelines that facilitate increased physical activity for residents of all ages and abilities.
   1. Fact Sheet: Promoting Complete Streets
      Describes steps municipalities can take to create, implement or enhance Complete Streets policies.
   2. CDC Vital Signs on Physical Activity and Disability
      Adults with disabilities who get no physical activity are 50% more likely to have certain chronic diseases than those who get the recommended amount of physical activity. This Vital Signs toolkit promotes physical activity among adults with disability. The toolkit includes a Morbidity and Mortality Weekly Report, fact sheet with key messages and calls to action, digital press release, online videos and podcasts. Additional resources and strategies (Increasing Physical Activity among Adults with Disabilities) are also provided by CDC.

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Goal #1.2 (Action Plan) (Dashboard): Prevent childhood obesity through early child-care and schools.

1. Adopt regulations and policies designed to implement standards that will support breastfeeding, quality nutrition, increased physical activity and reduced screen time in early child care settings. Increase staff training, community support and reinforcement of these regulations and policies.
   1. Fact Sheet: Promoting Nutrition Standards For Healthy Food and Beverage Procurement
      Identifies actions and resources to help worksites, municipal agencies, child care centers, groups homes, community-based organizations, and other institutions adopt improved nutrition standards through food procurement, advocacy, and other strategies.
   2. Fact Sheet: Increasing Breastfeeding
      Describes actions to promote breastfeeding exclusivity in the first 6 months of life and continued breastfeeding duration for the infant's first year.
   3. Preventing Childhood Obesity in Early Care and Education Programs
      Provides the national standards describing evidence-based best practices in nutrition, physical activity and screen time.
   4. QUALITYstarsNY Program Standards
      Helps programs/providers understand the significance of the QUALITYstarsNY's program standards for high quality early education and demonstrates exemplary practices through supporting documentation. Sponsored by the New York State Early Childhood Advisory Council.
   5. National Resource Center for Health and Safety in Child Care and Early Education Toolkits:
      These toolkits were developed to support child care licensing personnel and child care providers in ensuring environments that promote healthy weight by focusing on high-impact standards of best practice related to infant feeding, avoiding or limiting foods high in sugar, using water and 100% juice and limiting screen time. A toolkit is available for each of these topics:
      1. Licensing Toolkit: Infant Feeding Practices
         This National Resource Center for Health and Safety in Child Care and Early Education toolkit addresses the development and implementation of best practices and policies for the following topics: feeding on cue (initiation and cessation of feeding in response to an infant's behavior), feeding by a consistent caregiver, promoting breastfeeding, and the practice of feeding infants human milk.
      2. Licensing Toolkit: Use of Water and 100% Juice
         This National Resource Center for Health and Safety in Child Care and Early Education toolkit can help in local efforts to strengthen regulations for early care and education programs to ensure that when children in care receive fluids other than milk, that those fluids are either water or limited amounts of 100% juice.
      3. Licensing Toolkit: Avoid or Limit Foods High in Sugar
         This National Resource Center for Health and Safety in Child Care and Early Education toolkit helps communities construct stronger regulations for child care to ensure that children in out-of-home care receive meals and snacks that limit or exclude foods high in sugar content.
      4. Licensing Toolkit: Limit Screen Time in Child Care
         This National Resource Center for Health and Safety in Child Care and Early Education
2. Incorporate time into the school day so that students have adequate time to eat a nutritious lunch/snacks and engage in physical activity.
   1. Let's Move Schools
      Let's Move! is a comprehensive initiative, launched by First Lady Michelle Obama, dedicated to solving the challenge of childhood obesity within a generation. Site describes how to make schools healthier places to learn by providing quality nutrition, integrating physical activity during the day and teaching children about the importance of embracing a healthy, active lifestyle.
   2. National Association for Sport and Physical Education Advocacy Comprehensive School Physical Activity Program Policy Continuum
      This tool addresses ways to develop policies around school physical activity programs. The continuum is divided into sections based on the five components of a Comprehensive School Physical Activity Program, as defined by the National Association of Sport and Physical Education.
   3. DASH-NY Active Recess
      A mandatory daily active recess policy implementation guide, developed by the New York Academy of Medicine and community groups.
3. Increase the number of schools that establish strong nutritional standards for all foods and beverages sold and provided through schools.
   1. Fact Sheet: Promoting Nutrition Standards For Healthy Food and Beverage Procurement
      Identifies actions and resources to help worksites, municipal agencies, child care centers, groups homes, community-based organizations, and other institutions adopt improved nutrition standards through food procurement, advocacy, and other strategies.
   2. Center for Science in the Public Interest
      Provides information on how schools can and are implementing updated nutrition standards for school lunches.
4. Increase the number of school districts that meet the New York State Education Department Regulations of the Commissioner Section 135.4 - Physical Education.
   1. New York State Education Department Physical Education Regulations and Learning Standards
   2. New York State Association for Health, Physical Education, Recreation, and Dance
      This professional organization is for those interested in promoting health, physical education, recreation, and dance from kindergarten through higher education in New York.
5. Develop and provide support for the implementation, monitoring and enforcement of New York State Education Department learning standards for physical education and nutrition in grades K-12.
   1. New York State Education Department Physical Education Regulations and Learning Standards
   2. Comprehensive School Physical Activity Program
      A multi-component approach by which school districts and schools use all opportunities for students to be physically active.
   3. New York State Association for Health, Physical Education, Recreation, and Dance
   4. New York State Education Department Child Nutrition

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Goal #1.3 (Action Plan) (Tracking Indicators) (Dashboard): Expand the role of health care and health service providers and insurers in obesity prevention.

1. Ensure public and private health insurance coverage of, access to and incentives for breastfeeding education, lactation counseling and support.
   1. For NYS Medicaid Coverage of Lactation Counseling
   2. NYS Medicaid Coverage of Breast Pumps
   3. NYS Minimum Breast Pump Specifications for Medicaid Reimbursement
2. Ensure public and private health insurance coverage of, access to and incentives for routine obesity prevention screening, diagnosis and treatment, including diabetes prevention programs.
   1. For Health Insurance Providers
      Harvard summarizes obesity prevention recommendations for health insurance providers, based on guidance from the American Academy of Pediatrics, Institute of Medicine, America's Health Insurance Plans, and others.
3. Increase the capacity of primary care providers to implement screening, prevention and treatment measures for obesity in children and adults through quality improvement methods and other training approaches, reimbursement and payment incentives.
   1. NACCHO Quality Improvement Training Materials
      Association of city and county health officials developed materials to help local health departments introduce quality improvement basics to their staffs.
   2. National Quality Center Quality Improvement Training
      These workshop materials can help facilitators conduct interactive group exercises to promote quality improvement. While this training is focused on HIV providers, the concepts are universal and can be adapted.
   3. AHRQ Practice Facilitation Guide
      The practice facilitation programs described in this guide are designed to work with primary care practices on quality improvement activities, with an emphasis on primary care redesign and transformation. The guide focuses on how to establish and run an effective practice facilitation program and is intended for organizations or individuals who will develop, design, and administer such programs.
   4. CDC Vital Signs on Physical Activity and Disability
      Adults with disabilities who get no physical activity are 50% more likely to have certain chronic diseases than those who get the recommended amount of physical activity. This Vital Signs toolkit promotes physical activity among adults with disability. The toolkit includes a Morbidity and Mortality Weekly Report, fact sheet with key messages and calls to action, digital press release, online videos and podcasts. Additional resources and strategies (Increasing Physical Activity among Adults with Disabilities) are also provided by CDC.
4. Establish professional training programs in prevention, screening, diagnosis and treatment of overweight and obesity. Training should reach across the spectrum of medical, nursing, physician assistant schools; dietetics; allied health programs such as community health workers; and in continuing education.
   1. Healthcare Professional Training and Advocacy
      Harvard summarizes obesity prevention recommendations for health care professional associations and professional advocacy, based on guidance from the Institute of Medicine, American Academy of Pediatrics, American Medical Association, and others.
5. Link health care-based efforts with community prevention activities such as comprehensive school-based obesity prevention programs; community-based, nationally recognized diabetes prevention programs; and breastfeeding counseling and support systems.
   1. Fact Sheet: Increasing Breastfeeding
      Describes actions to promote breastfeeding exclusivity in the first 6 months of life and continued breastfeeding duration for the infant's first year.
   2. Fact Sheet: Promoting Evidence-Based Interventions
      Identifies and explains steps to increase the availability, access and use of evidence-based interventions for prevention and control of chronic diseases through promotion and referral.
   3. CDC Vital Signs on Physical Activity and Disability
      Adults with disabilities who get no physical activity are 50% more likely to have certain chronic diseases than those who get the recommended amount of physical activity. This Vital Signs toolkit promotes physical activity among adults with disability. The toolkit includes a Morbidity and Mortality Weekly Report, fact sheet with key messages and calls to action, digital press release, online videos and podcasts. Additional resources and strategies (Increasing Physical Activity among Adults with Disabilities) are also provided by CDC.

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Goal #1.4 (Action Plan) (Dashboard): Expand the role of public and private employers in obesity prevention.

1. Increase the number of employers who offer benefits, coverage and/or incentives for obesity prevention, including breastfeeding support and obesity treatment.
   1. Fact Sheet: Increasing Breastfeeding
      Describes actions to promote breastfeeding exclusivity in the first 6 months of life and continued breastfeeding duration for the infant's first year.
   2. Worksite Obesity Prevention Recommendations
      Harvard summarizes obesity prevention recommendations for worksites, based on guidance from the Centers for Disease Control and Prevention, World Health Organization, Wellness Council of America, and others.
2. Strengthen business practices that are aligned with NYS Labor Law to support breastfeeding at work.
   1. Fact Sheet: Increasing Breastfeeding
      Describes actions to promote breastfeeding exclusivity in the first 6 months of life and continued breastfeeding duration for the infant's first year.
   2. People First: How to Plan Events Everyone Can Attend
      Provides tips on planning meetings, conferences, health fairs and other events in which everyone can participate.
3. Develop community partnerships to increase comprehensive worksite wellness programs among small- to medium-sized employers, and ensure that the programs are appropriate for people with disabilities.
   1. People First: How to Plan Events Everyone Can Attend
      Provides tips on planning meetings, conferences, health fairs and other events in which everyone can participate.
   2. CDC Vital Signs on Physical Activity and Disability
      Adults with disabilities who get no physical activity are 50% more likely to have certain chronic diseases than those who get the recommended amount of physical activity. This Vital Signs toolkit promotes physical activity among adults with disability. The toolkit includes a Morbidity and Mortality Weekly Report, fact sheet with key messages and calls to action, digital press release, online videos and podcasts. Additional resources and strategies (Increasing Physical Activity among Adults with Disabilities) are also provided by CDC.
4. Implement evidence-based wellness programs for all public and private employees, retirees and their dependents through collaborations with unions, health plans and community partnerships that include but are not limited to increased opportunities for physical activity; access to and promotion of healthful foods and beverages; and health benefit coverage and/or incentives for obesity prevention and treatment, including breastfeeding support.
   1. Fact Sheet: Increasing Breastfeeding
      Describes actions to promote breastfeeding exclusivity in the first 6 months of life and continued breastfeeding duration for the infant's first year.
   2. Fact Sheet: Promoting Nutrition Standards For Healthy Food and Beverage Procurement
      Identifies actions and resources to help worksites, municipal agencies, child care centers, groups homes, community-based organizations, and other institutions adopt improved nutrition standards through food procurement, advocacy, and other strategies.
   3. Healthy Meeting Guidelines
      NYS Department of Health recommendations for refreshments and breaks at meetings to encourage healthy choices.
   4. Steps to Wellness: A Guide to Implementing the 2008 Physical Activity Guidelines for Americans in the Workplace - the Centers for Disease Control and Prevention.
5. Increase adoption of food procurement and vending policies based on the Dietary Guidelines for Americans among public and private employers, including government agencies.
   1. Fact Sheet: Promoting Nutrition Standards For Healthy Food and Beverage Procurement
      Identifies actions and resources to help worksites, municipal agencies, child care centers, groups homes, community-based organizations, and other institutions adopt improved nutrition standards through food procurement, advocacy, and other strategies.
   2. Healthy Hospital Food Toolkit
      Adapted from materials produced by the New York City Department of Health and Mental Hygiene.
   3. Healthy Workplace Toolkit
      Adapted from materials produced by the New York City Department of Health and Mental Hygiene.

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Focus area 2 - Reduce Illness, Disability and Death Related to Tobacco Use and Secondhand Smoke Exposure

Goal #2.1 (Action Plan) (Dashboard): Prevent initiation of tobacco use by New York youth and young adults, especially among low socioeconomic status (SES) populations.

1. Increase Tobacco Control Program funding to the CDC-recommended level, utilizing revenue from NYS tobacco excise tax to fund a comprehensive tobacco control program, as resources become available.
   1. Best Practices for Comprehensive Tobacco Control Programs
      CDC's evidence-based guide to help states plan and establish effective programs to prevent and reduce tobacco use.
   2. Advancing Tobacco-Free Communities contractor.
2. Use media and health communications to highlight the dangers of tobacco, promote effective tobacco control policies and reshape social norms.
   1. Advancing Tobacco-Free Communities contractor.
3. Pursue policy action to reduce the impact of tobacco marketing in ower-income and racial/ethnic minority communities.
   1. Fact Sheet: Protecting Youth from Tobacco Marketing in the Retail Environment
   2. Public Health and Tobacco Policy Center - Ways and Means - Point of Sale Policy: New York Communities Taking Action (March 2016)
      New York State guide provides information and examples of communities reducing the tobacco industry's influence in the retail environment.
   3. Public Health and Tobacco Policy Center - Retail Environment
4. Additional information and resources on point of sale policy options.
   1. Public Health and Tobacco Policy Center, Product Pricing
      Provides policy responses to tobacco industry price manipulation.
   2. Best Practices for Comprehensive Tobacco Control Programs
      CDC's evidence-based guide to help states plan and establish effective programs to prevent and reduce tobacco use.
5. Increase community interventions, especially in disadvantaged urban neighborhoods and rural areas.
   1. Best Practices for Comprehensive Tobacco Control Programs
      CDC's evidence-based guide to help states plan and establish effective programs to prevent and reduce tobacco use.

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Goal #2.2 (Action Plan) (Tracking Indicators) (Dashboard): Promote tobacco use cessation, especially among low SES populations and those with poor mental health.

1. Use health communication to increase the impact and utilization of the NYS Smoker's Quitline, particularly among disparate populations.
   1. Best Practices for Comprehensive Tobacco Control Programs
      CDC's evidence-based guide to help states plan and establish effective programs to prevent and reduce tobacco use.
   2. New York State Smokers' Quitline
      Provides free call or click quit services to tobacco users, and information, resources and technical assistance to employers, health plans, and health care organizations and providers.
2. Help health care organizations and providers establish policies, procedures and practices to facilitate the delivery of tobacco dependence treatment, consistent with the Public Health Service Clinical Practice Guidelines, with a focus on Federally Qualified Health Centers and behavioral health providers.
   1. Technical assistance can be obtained by contacting your local Health Systems for a Tobacco-Free NY grantee. (PDF)
   2. TalkToYourPatients.ny.gov
      New York State Department of Health website with information and resources on evidence-based tobacco dependence treatment.
3. Advocate for expanded Medicaid and other health plan coverage of tobacco dependence treatment counseling and medications.
4. Promote smoking cessation benefits among Medicaid beneficiaries and providers.
   1. Technical assistance can be obtained by contacting your local Health Systems for a Tobacco-Free NY grantee.
   2. TalkToYourPatients.ny.gov
      New York State Department of Health website with information and resources on evidence-based tobacco dependence treatment.

Goal #2.3 (Action Plan) (Dashboard): Eliminate exposure to secondhand smoke.

1. Promote smokefree policies in multi-unit housing, including apartment complexes, condominiums and co-ops, especially those that house residents of lower socioeconomic status.
   1. Fact Sheet: Promoting Smoke-Free Polices in Multi-Unit Housing
      Strategies to increase the number of local housing authorities that adopt tobacco-free polices for all units.
   2. SmokeFreeHousingNY.org
      New York State Department of Health-funded website provides information, resources and model smoke-free housing policies for landlords, tenants, and condominium and co-op boards.
2. Increase the number of smoke-free parks, beaches, playgrounds, college and hospital campuses, and other public spaces.
   1. Technical assistance can be obtained by contacting your local Advancing Tobacco-Free Communities grantee.
3. Advocate with organizational decision makers, conduct community education, and use paid and earned media to increase community knowledge of the dangers of second-hand smoke exposure.
   1. Technical assistance can be obtained by contacting your local Tobacco Control Community PartnershipAdvancing Tobacco-Free Communities grantee.

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Focus Area 3: Increase Access to High Quality Chronic Disease Preventive Care and Management in Both Clinical and Community Settings

Goal #3.1 (Action Plan) (Dashboard): Increase screening rates for cardiovascular disease, diabetes and breast, cervical and colorectal cancers, especially among disparate populations.

1. Use media and health communications to build public awareness and demand.
   1. Making Health Communication Programs Work
      Provides a detailed guide for the design, implementation and evaluation of a health communication program.
2. Foster collaboration among community-based organizations, the education and faith-based sectors, independent living centers, businesses and clinicians to identify underserved groups and implement programs to improve access to preventive services.
   1. Collective Impact
      Describes the efforts of countless teachers, administrators, and nonprofits, who together with billions of dollars in charitable contributions, have led to important improvements in individual schools and classrooms and can be viewed as a framework for fostering collaboration to improve access to preventive services.
   2. Making Collective Impact Work
      This follow-up on the popular "Collective Impact" article provides updated, in-depth guidance for fostering effective collaborations within communities.
   3. Catalytic Philanthropy
      Despite spending vast amounts of money and helping to create the world’s largest nonprofit sector, philanthropists have fallen far short of solving America’s most pressing problems. What the nation needs is “catalytic philanthropy”—a new approach that is already being practiced by some of the most innovative donors.
   4. The Work of Leadership
      Authors introduce the breakthrough concept of adaptive change—the sort of change that occurs when people and organizations are forced to adjust to a radically altered environment—and challenge the traditional understanding of the leader-follower relationship.
   5. FSG-Social Impact Consultants
      FSG is a nonprofit consulting firm specializing in strategy, evaluation, and research. Their teams work across sectors by partnering with foundations, corporations, nonprofits, and governments to develop more effective solutions to challenging social issues.
   6. Bridgespan Group
      The Bridgespan Group is a nonprofit advisor and resource for mission-driven organizations and philanthropists that collaborates with social sector leaders to help scale impact, build leadership, advance philanthropic effectiveness and accelerate learning.
   7. Monitor Institute
      Monitor Institute is a social enterprise that surfaces and spreads best practices in public problem solving and pioneers next practices by partnering with mission-driven organizations and their leaders, helping them make the hard choices and take the necessary actions to reach a new level of impact.
   8. Tamarack Institute
      Tamarack is a charity that develops and supports learning communities to help people collaborate and to co-generate knowledge that solves complex community challenges.
3. Establish training programs across the health professional spectrum, to include enhancement of patient-centered skills, disability literacy and providers' cultural competence.
   1. Culturally Competent Healthcare Systems: A Systematic Review
      American Journal of Preventive Medicine reviews five interventions to improve cultural competence in health care systems.
   2. Developing Physician Communication Skills for Patient-Centered Care
      Health Affairs article describes the skills for excellent patient-centered communication and reviews their impact on patient outcomes.
   3. Communication Skills for Patient-Centered Care
      Journal of Bone and Joint Surgery describes research-based, easily learned techniques for medical interviews that benefit orthopedic surgeons, other physicians and patients.
   4. Desired Educational Outcomes of Disability-Related Training for the Generalist Physician: Knowledge, Attitudes, and Skills
      Academic Medicine journal article asserts that quality primary care is a critical linchpin to improve the health status of persons with disabilities. Authors examine disability-related training for generalist physicians by summarizing the empirical data.
4. Ensure consumer access to and coverage for preventive services, and enhance reimbursement and incentive models.
   1. Seven Ways Physicians Can Improve the Delivery of Preventive Care to Their Patients: Health Systems Recommendations from the Guide to Community Preventive Services
      Guide reviews the effectiveness of population-level health interventions, including strategies implemented in health care settings to improve the delivery of preventive services.
   2. Updated Recommendations for Client- and Provider-Oriented Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening: Community Preventive Services Task Force
      Nine interventions to increase screening for breast, cervical and colorectal cancer.
   3. Research Tested Intervention Programs
      National Cancer Institute offers physician interventions to reduce barriers to breast cancer screening
   4. An Educational Approach to Improving Physician Breast Cancer Screening Practices and Counseling Skills
      A multifaceted, individualized education program to increase the breast cancer screening practices of community-based primary care physicians is described and evaluated.
   5. Patient Incentive Models
      A list of studies on reducing out-of-pocket costs for cardiovascular disease preventive services for patients with high blood pressure and high cholesterol.
5. Expand use of health information technology to remind, provide feedback and incentivize clinicians and health care systems.
   1. A Diabetes Dashboard and Physician Efficiency and Accuracy in Accessing Data Needed for High-Quality Diabetes Care
      Annals of Family Medicine article compares a new diabetes dashboard screen to a conventional approach of viewing multiple electronic health record screens to find data needed for ambulatory diabetes care.
   2. Meaningful Use of Electronic Prescribing in 5 Exemplar Primary Care Practices
      Annals of Family Medicine article details a case study of five ambulatory primary care practices identified as exemplars of effective e-prescribing.

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Goal #3.2 (Action Plan) (Dashboard): Promote evidence-based care to manage chronic diseases.

1. Support the adoption and use of electronic health records.
   1. A Diabetes Dashboard and Physician Efficiency and Accuracy in Accessing Data Needed for High-Quality Diabetes Care
      Annals of Family Medicine article compares a new diabetes dashboard screen to a conventional approach of viewing multiple electronic health record screens to find data needed for ambulatory diabetes care.
   2. Meaningful Use and Public Health
      NYS Department of Health's Meaningful Use Web site.
   3. Meaningful Use of Electronic Prescribing in 5 Exemplar Primary Care Practices
      Annals of Family Medicine article details a case study of five ambulatory primary care practices identified as exemplars of effective e-prescribing.
2. Promote the inclusion of decision support tools/reminder system modules in the basic electronic medical record packages offered by vendors.
   1. Effect of Clinical Decision-Support Systems: A Systematic Review
      Annals of Internal Medicine article demonstrates the benefits of commercially and locally developed Clinical Decision-Support Systems in the field, where they can be effective at improving health care process measures across diverse settings.
   2. Translating Evidence Into Practice
      Primary Care Development Corporation's step-by-step guide to implement a clinical decision support system for chronic disease management in the primary care setting.
   3. Clinical Decision Support
      Community Preventive Services Task Force recommendations and resources on clinical decision support and its effectiveness in improving screening for CVD risk factors and practices for CVD-related preventive care services, clinical tests, and treatments.
3. Adopt medical home or team-based care models, especially in practices that serve disparate communities.
   1. Recommended Healthcare System Interventions for Diabetes
      The Community Guide's systematic review focuses on population-based strategies to improve the care of people with either type 1 or type 2 diabetes.
   2. Team-Based Care Models
      List of studies describing team-based care to improve blood pressure control.
   3. Ensuring that Health Care Reform Will Meet the Health Care Needs of Minority Communities and Eliminate Health Disparities
      The federal Advisory Committee on Minority Health urges application of 14 principles and creates the impetus and infrastructure to eliminate health disparities and inequities.
   4. A Patient-Centered Guide to Implementing Language Access Services in Healthcare Organizations
      The Office of Minority Health in the U.S. Department of Health and Human Services sponsored development of this guide to help health care organizations implement effective language access services for their limited English-proficient patients, thereby increasing their access to health care.
   5. Patient Centeredness, Cultural Competence and Healthcare Quality
      National Institutes of Health article explores the historical evolution of cultural competence and patient centeredness and compares their conceptual models at the interpersonal and health care system levels to demonstrate similarities and differences.
   6. Disparities in Patient Experiences, Health Care Processes and Outcomes: The Role of Patient-Provider Racial, Ethnic and Language Concordance
      Commonwealth Fund research documents racial and ethnic disparities in health care and links patient-physician race and ethnic concordance with higher patient satisfaction and better health care processes.
   7. CDC Training on Community Health Workers' Role in Team-Based Care
      Describes how states can become engaged in policy and systems change efforts to establish sustainability for Community Health Workers.
   8. Million Hearts
      Visit Million Hearts® website for information on adding a pharmacist to your team to manage patients with chronic conditions like hypertension.
      Provides information about CDC's Million Hearts initiative.
   9. Access to Preventive Healthcare Services for Women with Disabilities.
      Association of State and Territorial Health Officials outline some major barriers that women with disabilities face when accessing preventive health care, along with solutions to consider.
   10. An Implementation Tool for Clinic Practice Teams
       Washington State Department of Health's tool to improve the screening, prevention and management of hypertension.
4. Provide technical assistance and quality improvement training to health care organizations and providers, especially those serving disparate communities.
   1. NACCHO Quality Improvement Training Materials
      Association of city and county health officials developed materials to help local health departments introduce quality improvement basics to their staffs.
   2. National Quality Center Quality Improvement Training
      This website includes  resources and training information to promote quality improvement in health care. While this information targets HIV providers, the concepts are universal and can be adapted.
   3. AHRQ Practice Facilitation Guide
      The guide focuses on how to establish and run an effective practice facilitation program, and is intended for organizations or individuals who will develop, design, and administer such programs.
   4. Practice Facilitation Handbook: Training Modules for New Facilitators and Their Trainers
      Provide technical assistance and quality improvement training to health care organizations and providers, especially those serving disparate communities.
   5. HRSA Quality Toolkit
      Provides technical assistance for organizations to support new or existing quality improvement programs covering multiple chronic conditions.
   6. Developing and Implementing a Quality Improvement Plan
      Health Resources and Services Administration developed this module to highlight the role of an effective quality improvement plan in improving performance of an organization's health care systems.
   7. Quality Improvement
      This module provides a foundation and an introduction to quality improvement (QI) concepts and key topics for developing or enhancing a QI program within an organization.
   8. Redesigning a System of Care to Promote Quality Improvement
      This module highlights the role that redesigning health care systems within an organization has on overall quality.
   9. Million Hearts: Hypertension Control Action Steps for Clinicians
      Tested strategies for busy clinicians to aid in efforts related to hypertension control.
   10. Increasing Physical Activity among Adults with Disabilities
       Resources and strategies for physicians and other health professionals to assist them in recommending physical activity to patients with disabilities.

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Goal #3.3 (Action Plan) (Tracking Indicators) (Dashboard): Promote culturally relevant chronic disease self-management education.

1. Implement policies to support coverage of chronic disease self-management programs
   1. Fact Sheet: Promoting Evidence-Based Interventions
      Provides the rationale and identifies actions to increase the availability, access and use of evidence-based interventions for prevention and control of chronic diseases through promotion and referral.
2. Develop a sustainable infrastructure for widely accessible, readily available self-management interventions that link community and clinical settings and make use of lifestyle intervention professionals such as registered dietitians, exercise physiologists and social workers
   1. Fact Sheet: Promoting Evidence-Based Interventions
      Provides the rationale and identifies actions to increase the availability, access and use of evidence-based interventions for prevention and control of chronic diseases through promotion and referral.
   2. Diabetes Self-Management Education Resources
      Resource list can help identify and locate resources to increase sustainable diabetes self-management education and support services.
3. Develop a sustainable infrastructure for widely accessible, readily available self-management interventions linked to the clinical setting
   1. Fact Sheet: Promoting Evidence-Based Interventions
      Provides the rationale and identifies actions to increase the availability, access and use of evidence-based interventions for prevention and control of chronic diseases through promotion and referral.
   2. Diabetes Self-Management Resource (Requires registration)
      Resources to help diabetes prevention and control programs and their partners to identify and locate resources relevant to increasing access to sustainable diabetes self-management education and support services.
   3. NYS Evidence-Based Programs Quality and Technical Assistance Center
      Center serves as the statewide coordinator of self-management interventions in New York. The website provides information about programs offered, local availability, delivery partners and technical assistance resources.
4. Establish clinical-community linkages that connect patients to self-management education and community resources, such as the NYS Smokers' Quitline
   1. Fact Sheet: Promoting Evidence-Based Interventions
      Provides the rationale and identifies actions to increase the availability, access and use of evidence-based interventions for prevention and control of chronic diseases through promotion and referral.
   2. Agency for Healthcare Research and Quality (AHRQ)
      Resources on clinical-community linkages.
   3. CDC's 1-2-3 Approach to Provider Outreach tool kit
      Guide to marketing self-management interventions to health care providers to increase awareness and patient referrals.
5. Use health information technology to support a clinical referral/recommendation system that links patients to community-based resources
   1. Fact Sheet: Promoting Evidence-Based Interventions
      Provides the rationale and identifies actions to increase the availability, access and use of evidence-based interventions for prevention and control of chronic diseases through promotion and referral.

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