Health Services Advisory Group (HSAG) provides services to physician offices in Arizona and California for chronic disease management, such as blood pressure control, diabetes care, smoking cessation, cardiac rehabilitation, and chronic kidney disease (CKD) care.
Program participants will find their work on these measures simultaneously enhances their current efforts to transition to value-based payment models and participate successfully in the federal Quality Payment Program (QPP). Contact us to register for services and receive no-cost technical assistance.
Chronic Disease Management
- 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/
- 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
- Teach-back resources: http://www.teachbacktraining.org/using-the-teach-back-toolkit
- About DSMEs: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/DSMT-Fact-Sheet-909381Print-Friendly.pdf
- Connected Care: The Chronic Care Management Resource—CMS provides resources and tools that can help healthcare professionals learn how to implement chronic care management (CCM) and receive payment for providing these services.
- 2022 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
- Hypertension Control Change Package for Clinicians (PDF): https://millionhearts.hhs.gov/files/HTN_Change_Package.pdf
- Self-Measured Blood Pressured 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
- Tobacco Cessation
- Change Package―Tobacco Cessation (PDF): https://millionhearts.hhs.gov/files/tobacco_cessation_change_pkg.pdf
- Protocol for Identifying and Treating Patients Who Use Tobacco (PDF)
- California Smokers' Helpline: https://kickitca.org/
- Arizona Smokers' Helpline: https://www.azdhs.gov/ashline/
- Atherosclerotic Cardiovascular Disease (ASCVD) Risk Estimator: https://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/
- Cardiac Rehabilitation Change Package (PDF): https://millionhearts.hhs.gov/files/Cardiac_Rehab_Change_Pkg.pdf
- Clinician Recognition Programs:
- Target BP Recognition Program: https://targetbp.org/recognition-program/
- Hypertension Control Challenge: https://millionhearts.hhs.gov/partners-progress/champions/challenge.html
- Connected Care: The Chronic Care Management Resource—CMS provides resources and tools that can help healthcare professionals learn how to implement chronic care management (CCM) and receive payment for providing these services.
- 2022 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
- Chronic Kidney Disease (CKD) Guide for Primary Care: https://www.cms.gov/files/document/chronic-kidney-disease-disparities-educational-guide-primary-care.pdf
- National Kidney Foundation: How to Manage Your CKD Patients: https://www.kidney.org/sites/default/files/02-10-6800_ABG_PCPI_Algorithm2_0.pdf
- Managing CKD: https://www.niddk.nih.gov/health-information/kidney-disease/chronic-kidney-disease-ckd/managing
- Connected Care: The Chronic Care Management Resource—CMS provides resources and tools that can help healthcare professionals learn how to implement chronic care management (CCM) and receive payment for providing these services.
- Cost Containment and CKD (PDF)
- A Toolkit to Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings
Quality Payment Program
- 2022 QPP Overview (PDF)
- 2022 Merit-based Incentive Payment System (MIPS) QPP Countdown (PDF)
- 2022 QPP Documents for an Audit (PDF)
- Questions to Ask Your EHR Vendor for MIPS 2022 Reporting (PDF) a.k.a. MIPS EHR Guide
- 2022 No-EHR MIPS Action Plan (PDF)
- 2022 QPP Final Rule Changes to MIPS Highlights (YouTube video)
- 2022 Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) Medicare Part B Claims Measure Specification Sheet (PDF)
- 2022 Controlling High Blood Pressure Medicare Part B Claims Measure Specification Sheet (PDF)
- Six Building Blocks: A Team-Based Approach to Improving Opioid Management in Primary Care
electronic health record = EHR
2022 MIPS Tips
- Cardiology (PDF)
- Endocrinology (PDF)
- Family Medicine (PDF)
- Internal Medicine (PDF)
- Nephrology (PDF)
Physician Practices Newsletter
Emergency Preparedness
- 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.
