Chronic Disease Management
Better Together.Chronic diseases are the leading cause of death and disability in the United States. They also are a key reason for rising healthcare costs.
- Eight of ten adults 65 and older have at least one chronic condition and approximately seven in ten have two or more.
- People affected by multiple chronic conditions are at risk of early mortality, poor functional status, and hospitalization. They also face significant out-of-pocket expenses for healthcare and prescription drugs.
Our goal is to help providers with the prevention and management of chronic diseases by supporting providers in preventing cardiovascular events, promoting tobacco cessation, improve the management of diabetes to decrease diabetes complications, identifying people at high risk for developing diabetes and chronic kidney disease. We have also included patient and family engagement and advance care planning as elements in chronic disease management.
Healthy behaviors directly contribute to positive health outcomes. Chronic disease self-management education programs also impact the development of long-term change for a healthy lifestyle. Improving health outcomes related to chronic conditions must be a joint effort between the healthcare professionals, the community, and the individual. From identifying at-risk individuals to providing self-management education and support, every individual contributes to and benefits from a collaborative approach.
Explore what we have provided under each topic below and choose which resource best fits your needs.
Chronic Disease Management News
News
Great Plains QIN New Tool: When To Call For Help
GPQIN Webinar: Break the Chain of Nicotine Dependence | May 23, 2023
ABCS for Stroke Awareness Month
My Life Check® I Good Habits Build Better Health
Advance Care Planning
Cardiovascular
ND – Heart Disease & Stroke Prevention Program
ND – NDC3-Connecting You to Community Health Programs
SD – Department of Health: Heart Disease and Stroke Prevention
SD – Better Choices Better Health
2022 American Heart Month Toolkits
American Heart Association (AHA) – Do You Know Your BP Numbers
AHRQ SHARE Approach Workshop Curriculum
CDC-Heart Disease
Cardiac Rehab
Million Hearts® Campaign – Cardiac Rehabilitation Change Package
Immunizations
Educating Adults with Chronic Health Conditions: Vaccination Resources
Million Hearts Tools and Resources
Million Hearts® 2022
Million Hearts Cholesterol Management Protocols
Million Hearts Hypertension Control Change Package for Clinicians
Million Hearts Self-Measured Blood Pressure Monitoring Tools
Chronic Kidney Disease
Diabetes
ND – NDC3-Connecting You to Community Health Programs
ND – Dakota Diabetes Coalition
ND – Diabetes Prevention and Control
SD – Better Choices Better Health
SD – Diabetes Coalition
SD – Diabetes Prevention & Control
ADCES-Association of Diabetes Care & Education Specialists
AHRQ SHARE Approach Workshop Curriculum
American Diabetes Association
CDC – Diabetes
CDC Diabetes Self-Management Education and Support Toolkit
CDC When Diabetes Self-Management Education is Emergency Medicine
RHIhub-Rural Diabetes Prevention and Management Toolkit
Diabetes Prevention
ND – NDC3: Connecting You to Community Health Programs
ND – Live Better-Virtual National DPP
ND – Dakota Diabetes Coalition
SD – Live Your Best – Virtual National DPP
SD – Undo the Risk – Prediabetes
SD – Diabetes Coalition
SD – Diabetes Prevention and Control
SD – Better Choices Better Health
American Diabetes Association – Diabetes Pro©
Powerful Tools for Caregivers
AHRQ SHARE Approach Workshop Curriculum
CDC Diabetes Resources
DPP Location Finder
Medicare DPP sites
National Diabetes Prevention Program Coverage Toolkit
Association of Diabetes Care & Education Specialists (ADCES)
Engagement of Patients and Families
ND – NDC3-Connecting You to Community Health Programs
SD – AARP & South Dakota 211 Helpline Center
SD – Better Choices Better Health
Great Plains QIN – Teach-Back Training
Great Plains QIN – Motivational Interviewing Handout
AHRQ SHARE Approach Workshop Curriculum
AHRQ – Guide for Developing a Community-Based Patient Safety Advisory Council
AHRQ – Guide to Patient and Family Engagement in Hospital Quality and Safety
Motivational Interviewing – Engage and Support for Change
CDC – Caring for Yourself When Caring for Another
CMS – Person and Family Engagement Toolkit
PCPCC – 6 Steps to Creating a Culture of Person and Family Engagement in Health Care
Powerful Tools for Caregivers
Video – Motivational Interviewing-Foundation for Patient-Centered Care
Tobacco Prevention
NEW – Great Plains QIN Break the Chain of Nicotine Dependence Change Package
South Dakota Quitline
South Dakota Tobacco Control and Prevention
Be Tobacco Free South Dakota
American Lung Association: Quit Smoking
National Behavioral Health Network for Tobacco & Cancer Control
Smokefree.gov
CDC Clinical Cessation Tools
Substance Abuse and Mental Health Services Administration (SAMHSA)
Tobacco Cessation Change Package
Tobacco Free Life
University of California San Francisco Smoking Cessation Leadership Center
Chronic Care Management Visits
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Great Plains Quality Care Coalition
Our Vision: Through collaboration and partnership, we aspire to make healthcare in the Dakotas the best in the nation. We have partnered with committed nursing homes, community leaders and healthcare organizations to improve the care in our communities. Better together.