Million Hearts Tools for Change Resources

Community-Clinical Linkages

Blood Pressure Self-Monitoring and Management (Public Health and Health Care Provider Resources)

Improve Care with Patient Self-Management Support [video]
The American Academy of Family Physicians (AAFP) explains why physicians should provide patient-centered, self-management support care; demonstrates how to use motivational interviewing, health coaches, and group visits to improve patient care and practice efficiency.

Self-Management Support Portal
This AHRQ web resource aims to help clinicians teach their patients how to take informed responsibility for their own health care. This web resource includes links to tools, resources, guides, and evidence.

Check. Change. Control. Blood Pressure Monitoring Program
This resource from the American Heart Association empowers people to monitor and manage their blood pressures through a combination of resources, including AHA's web-based tracking tool, Heart360®.

Heart360 Cardiovascular Wellness Center
AHA introduces Heart360®, an online tool to help track and manage individual heart health, along with providing helpful advice and information.

Physician Resource Guide to Patient Self-Management Support
The American Medical Association reviews and summarizes research and information sources on patient behavior and self-management support; provides responses to questions and links to relevant resources.

Self-Management Strategies for Vulnerable Populations [video]
The American Medical Association presents the challenges of providing care for patients with multiple chronic conditions, and presents five steps to providing self-management support: assessment, instruction, collaboration, implementation, and continuous support.

Motivating Patients to Change Behavior [video]
The American Medical Association provides a web-based video training module for providers.

Helping Patients Help Themselves: How to Implement Self-Management Support
The California Healthcare Foundation provides a guide for clinicians and practices that addresses barriers and lessons learned in making self-management support routine for clinical care for patients with chronic illness.

Partnering in Self-Management: A Toolkit for Clinicians 
Co-developed by the McColl Center, Robert Wood Johnson Foundation, and the Institute for Healthcare Improvement; this toolkit provides clinical practices with tested resources and tools to share with patients and families in the day-to-day management of chronic conditions.

Self-Measured Blood Pressure Monitoring: Action Steps for Public Health Practitioners [slide deck]
This Million Hearts Action guide document provides action steps for public health practitioners to facilitate the implementation of SMBP plus additional support in five key areas: understanding the environment, working with payers and purchasers, working with health care providers, spreading the word to the public, and monitoring/assessment of SMBP plus additional support implementation.

Local Health Departments Support Chronic Disease Self-Management Programs
NACCHO's guide discusses their efforts to support local health departments develop or enhance their capacity to deliver effective chronic disease self-management programs.

National Forum Learning Session: Linking Patient Data from the Community to Clinical Practice
The National Forum and ASTHO have recorded a series of short conversations with clinicians to discuss how to implement policies, practices and system strategies that improve control of high blood pressure in patients. This conversation features Dr. Hayden Bosworth, Research Professor at Duke University Medical Center, discussing the role of home blood pressure monitoring.

Stanford's Chronic Disease Self-Management Program
Stanford University School of Medicine offers a workshop in community settings for people with different chronic health problems to attend.

Health Care Access Hypertension FITT Program (Kansas)
Healthcare Access Clinic offers a guide to the implementation of the best practices and evidence-based policies for identifying, controlling, and improving blood pressure. Page 10 of Kansas' Healthcare Access Clinic Wellness Program guide outlines their nutrition program. Page 17 of Kansas' Healthcare Access Clinic Wellness Program guide outlines their goal sheet.

ASTHO Million Hearts Success Story: New York Develops Clinical Pathway to Identify and Manage Adult Hypertension
Through the ASTHO Million Hearts State Learning Collaborative, one local clinic in New York is working with the New York State Department of Health (NYSDOH) and other state and local partners to develop and implement a standardized clinical pathway to identify and manage patients with uncontrolled and undiagnosed hypertension.

Patient-Self Monitoring of Blood Pressure: A Provider's Guide (New York)
New York City provides guidance on introducing self-measured blood pressure monitoring and recommended protocols for providers.

ASTHO Million Hearts Case Study: Ohio's "Check It, Change It, Control It" Toolkit
This toolkit was produced by the Ohio Department of Health (ODH) and the Ohio Academy of Family Physicians (OAFP). It was designed to increase screening among African-American males for hypertension and high cholesterol and improve their preventive behaviors and treatment by focusing on both patient education and physician training in care management and cultural sensitivity.

Check It. Change It. Control It. Your Heart Depends On It. (Ohio)
The Ohio Academy of Family Physicians provides links to the materials included in Ohio's "Check It. Change It. Control It. Your Heart Depends On It." Toolkit. Resources includes physician guides, patient toolkits, and mobile apps.

Modified DASH Diet (Vermont) 
This two-page patient handout, developed by the Vermont Department of Health, offers a sample eating plan and daily menu structured around the Dietary Approaches to Stop Hypertension (DASH) diet.

Video on DASH Diet for Providers and Clinical Staff (Vermont)
The Vermont Department of Health collaborated with Rutland Regional Medical Center’s Community Health Team to produce an 8 minute video about the science behind the DASH Eating Plan.  The video also addresses how to use motivational interviewing as part of a short patient visit, in different “stages of change” regarding a person’s readiness for behavior improvement.


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