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Physician Practices

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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

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Assess social drivers of health (SDOH) 

Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) is a national standardized patient risk assessment tool designed to engage patients in assessing and addressing SDOH.

  • Review the PRAPARE Implementation and Action Toolkit to understand how to gather, assess, and respond to SDOH data.
  • Use the PRAPARE Readiness Assessment Tool to evaluate your organization's readiness to support your health center members in implementing PRAPARE and using PRAPARE data.
  • Use the PRAPARE Screening Tool to collect and assess patient SDOH data. This tool includes 17 core questions and 4 optional questions about SDOH. Its toolkit includes the four electronic health record (EHR) tools, technical resources, best practices, multiple tested workflows, and other resources. This screening tool is available in 33 languages.

Address SDOH

Provide culturally and linguistically appropriate services (CLAS) by using these tools:

  • A how-to guide on Providing CLAS (PDF) —This handout from the U.S. Department of Health & Human Services Office of Minority Health gives clear instructions on communication, health literacy, using teach back, language assistance, applying the LEARN model, strategies for listening/learning, and partnership building.
  • A guide to implement the Arthur Kleinman's Eight Questions (PDF) explanatory model
  • A checklist to aid in Working Effectively With an Interpreter (PDF)
  • Tool to understand and implement the RESPECT model (PDF)
  • A checklist (PDF) to ensure effective cross-cultural communication skills
  • Neighborhood Navigator from the American Academy of Family Physicians is an interactive tool to connect patients with supportive resources in their neighborhood. Look up by ZIP Code.

Quality Payment Program

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