Care + Community + Equity

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Care + Community + Equity

Through Care + Community + Equity (CCE) the Diabetes, Heart Disease and Stroke Program (DHDS) at the Rhode Island Department of Health (RIDOH) seeks to improve population health outcomes and the quality of care for people with or at risk of diabetes and cardiovascular disease. As a quality improvement initiative, CCE consists of three focus areas:

  1. Diabetes Control and Prevention
  2. Cardiovascular Disease Management and Prevention
  3. Self-Measurement of Blood Pressure

Rhode Island’s Federally Qualified Health Centers and free clinics were invited to participate in January 2019. Since then, five Federally Qualified Health Centers and two free clinics have maintained participation in CCE by implementing quality improvement projects, submitting quarterly data for clinical quality measures, and attending quarterly best practice sharing meetings.

 

 

Diabetes Control and Prevention (Prediabetes) - Year 4 Scope of Work
Cardiovascular Disease Management and Prevention - Year 4 Scope of Work
Self Measurement of Blood Pressure - Year 4 Scope of Work
Measurement Specifications - Year 4 Scopes of Work

Link To CTC-RI/RIDOH Portal for Data Entry

The links below include information on SMBP/hypertension, Cholesterol, and Hypertension. 

SMBP / Hypertension
Cholesterol
Hypertension
Common Errors of BP Measurement ¿Que Significan Mis Niveles De Colesterol? A Three Pillar Approach to Addressing Hypertension 
High Blood Pressure How to Make Control Your Goal ¿Como Puedo Mejorar MI Colesterol? Hypertension Control Challenge | Million Hearts® 
How to Measure Blood Pressure The Scoop On Statins: What Do You Need To Know?  
 MCDPH Cuff Size Chart Cholesterol Drugs High Blood Pressure How to Make Control Your Goal
SMBP At-A-Glance Comparison Tool Cholesterol Score Improving Medication Adherence Among Patients with Hypertension
Clinician’s Lifestyle Modification Toolbox | National Lipid Association Online  Heart Disease Spotlight : RAcial and Ethnic Disparities  Million Hearts®—Evidence-based Hypertension Treatment Protocols
Checking SMBP Equipment Accuracy How Can I Improve My Cholesterol? Know the Facts About Heart Disease
SMBP Guide |NAHC.org  How Do My Cholesterol Levels Affect My Risk? Know the Facts About High Blood Pressure
 Engaging Patients in Self-Measurement Know the Facts About High Cholesterol Know the Facts About Stroke
Loaner Device Management Medicine Chart Supporting Your Patients with High Blood Pressure
 Integrating SMBP into Care Processes & Workflows Video Session My Cholesterol Guide Hypertension Control Change Packages and Action Guides
NACHC Health Care Delivery SMBP Implementation Guide Promotora Guide Blood Pressure Categories
Patient Participation in Self-Measured Blood Pressure Program Loaner Agreement What Are High Blood Cholesterol and Triglycerides? AMA Improve BP Control in Your Practice
PT1 - Sample Cover Letter for Packets What Are Cholesterol-Lowering Medications? Supporting Your Patients with High Blood Pressure
PT3 - Sample SMBP Loaner Agreement CDC Cholesterol Communications Kit

Live to the Beat Campaign 

PT5 - Sample SMBP Equipment Loaner Tracking Sheet

Resources | LDC-Limbo: Lowering to Desired Levels of Cholesterol: Lasting Improvements and Meaningful Benefits Overall

Link to Target: BP

Sample Cover Letter for Packets Clinician's Lifestyle Modification Toolbox | National Lipid Association Online  Best Practices for Heart Disease and Stroke: A Guide to Effective Approaches and Strategies
Self-Measured Blood Pressure Loaner Program Tracking Sheet 2018 Prevention Guidelines Tool CV Risk Calculator (heart.org) 

The Surgeon General’s Call to Action to Control Hypertension

Self-Measured Blood Pressure Log Sheet What is FH?   
Self-Measured Blood Pressure Monitoring    
SMBP Device Accuracy Test    
SMBP Loaner Device Agreement    
SMBP Loaner Device Inventory Management    
SMBP Monitoring Program    
SMBP Workflow    
10 Best Blood Pressure Apps    
US BP Validated Device Listing    
Remote Patient Monitoring Insights  

 

The Importance of Using Validated Devices Video Session 

   
A Three Pillar Approach to Addressing Hypertension     
Hypertension Control Challenge | Million Hearts®     
High Blood Pressure How to Make Control Your Goal    
Improving Medication Adherence Among Patients with Hypertension    
Know the Facts About Heart Disease    
Know the Facts About High Blood Pressure     
National Hypertension Control Roundtable (NHCR) resources    

 

Diabetes
Prediabetes
Recorded Webinar: Diabetes Data and Statistisc | CDC  
Health Center Resource Clearinghouse: Diabetes Retrospective Prediabetes Identification
Diabetes and the Eyes Educational Toolkit  Preventing Type 2 Diabetes in At-Risk Patients
Diabetes Control and Management: Eye Health  Preventing Type 2 Diabetes
Diabetes Management and Oral Health  AMA Evidence Supporting DPP
Diabetes Prevention Strategies for the Whole Family  Disease Focus: Prediabetes
Promising Practices on Diabetes  Letter Template
Screening for Diabetes at Normal BMIs Could Cut Racial Disparities  M.A.P. (Measure, Act, Partner)
Lifestyle Changes Can Lead to Remission for Type 2 Diabetes but Not a Cure  Point-Of-Care Prediabetes Identification
Helping People with Diabetes Shift Their Mindset AMA Prevent Diabetes
Diabetes in the United States AMA Prevent Diabetes - Tools for the Team
Prevalence and Correlates of Diabetes Prevention Program Referral and Participation AMA Prevent Diabetes - Success Stories
Diabetes Book 2020 - English  Meeting Recording: AMA Insight Network Partnering with Patients to Prevent Diabetes
Diabetes Book 2018 – Spanish   
Know Diabetes by Heart™ | Managing Type 2 Diabetes and Heart Risks   
Diabetes Information and Resources for Primary Care | novoMEDLINK™   
CMS Diabetes Management: Directory of Provider Resources  

Continuous Glucose Monitoring:

 

 

Our Mission

The mission of the Care Transformation Collaborative of Rhode Island is to lead the transformation of primary care in Rhode Island in the context of an integrated health care system; and to improve the quality of care, the patient experience of care, the affordability of care, and the health of the populations we serve.