Community Health Network Program Referral
Healthcare Provider Information Provider Name
Date___ / ___ / ___
Agency / Practice
Phone__ __ __ - __ __ __ - __ __ __ __
Street Address
Fax__ __ __ - __ __ __ - __ __ __ __
City, Zip Code
E-Mail:
Send feedback to:
Same as above or Name:_______________ Phone: __ __ __ - __ __ __ - __ __ __ __ Fax: __ __ __ - __ __ __ - __ __ __ __
Patient Information Name
Gender:
Male
Female
Best Phone to call __ __ __ - __ __ __ - __ __ __ __ Birth Date ___ / ___ / ___
Best time to call: _________________________
Special accommodations? Language Spanish Other (Please Specify) ______________________________________________ Physical or other special needs:____________________________________________________________ Primary insurance: BCBS of RI United Healthcare Neighborhood Health Plan Tufts Medicare Medicaid (check one): __:Rite-Care __Connect Care __Rhody Health Other None Patient Concern Available Evidence-Based Programs (Choose one or more) Community Partner Programs (patient authorization required) Check all that apply Arthritis Foundation Exercise Walk With Ease Arthritis Draw a Breath (Pediatric Only) National Alliance on Mental Illness of Rhode Island (NAMI) Asthma Peer Resource Specialists Cancer Survivor YMCA COPD Health Smart Behaviors Healthy Lifestyles Behavior Change Program Salsa, Sabor Y Salud LIVESTRONG Diabetes Prevention Diabetes Department of Health Programs (patient authorization not required) Fall-risk Certified Cardiovascular Disease Outpatient Educator (CVDOE) Heart Disease Registered Dietitian Registered Nurse Registered Pharmacist Hypertension Certified Diabetes Outpatient Educator (CDOE)* Registered Dietitian Registered Nurse Registered Pharmacist Mental Health * Requires Physician/NP/PA Order. Must be signed and faxed to 222-4418 Non-Medical Needs Healthcare Provider Other Signature:____________________________________________________ Healthy Lifestyles for Youth with Special Needs Overweight Living Well Rhode Island Diabetes Self-Management Workshop Pain Chronic Disease Self Management Chronic Pain Self-Management Pre-Diabetes Matter of Balance: Managing Concerns About Falls Special Needs Youth QUiTWORKS-RI Rhode Island Smokers’ Quitline 1-800-QuitNow (Clients call directly for services) Tobacco Use Please Have the person being referred sign the authorization to disclose information only for Community Partner Programs Keep a copy for your records Provide the person referred with the Community Health Network Program Guide Send this form to Cindy Ariza through secure fax (401-222-4418) or secure email (
[email protected]). Call Cindy Ariza 401-222-7636 if you have any questions. Know that patient progress reports will be emailed or faxed to the number provided on this form. Revised 8/2/13
Dept. of Health use only: Date entered: ________ Entered by: _______ Referral ID number: ________
Authorization to Disclose Confidential Information about My Chronic Conditions for Better Self-Management Care
I, _______________________________________________________________________________ (Program Participant)
hereby voluntarily authorize disclosure of my name, address, phone number, date of birth and gender for the purpose of my referral to a chronic disease education and/or self-management program or services. My information is to be disclosed by:
(Name of Referring Practice/Organization)
(Street Address)
(City, State, Zip)
I understand that my personal information(listed above) may be shared only to help me better manage my health and only between and among my referring health care provider, the Rhode Island Department of Health, and individual or community program involved with chronic condition education /selfmanagement program or services to which I have been referred. Information to be shared include letting my referring health care provider know whether I participated in programs to which I was referred, and the outcome of my participation. I also understand that I may revoke this authorization at any time by writing to the healthcare provider who referred me to the programs. If I revoke this authorization my personal healthcare information will no longer be shared and will be protected by federal and state law. If this authorization has not been revoked, it will terminate one year from the date of my signature unless I have specified a later expiration date. _____________________________________
__________________________
Signature of Person Referred
Date
________________________________________________________________________________ Expiration Date of Authorization (One year from today, or later if you write a later date above.)
__________________________________________________ Signature of Authorized Representative of Healthcare Provider
Revised 8/2/13
____________________________________ Date
INSTRUCTIONS FOR USING THE CHRONIC CONDITION EDUCATION AND SELF-MANAGEMENT REFERRAL FORM
Under the Healthcare Provider Information box: Complete the information requested on the form for the referral provider or agency and the person being referred. Under the Patient Information box: Provide the referee’s name and demographic information. Make sure the person provides you with the best number to call and best time to call. Under Special Accommodations: Indicate any special needs the person being referred may have such as language or any physical accommodations such as ramp access, elevator, close proximity to speaker due to hearing issues, etc. Under Patient Concern: Check all the chronic conditions for which this person is being referred. If the condition is not on the list, please check the “Other” box. Under Available Evidence-Based Programs, select one or more programs to which you would like to refer this person. Program descriptions are provided on the Community Health Network Program Guide. For referrals to a Certified Diabetes Outpatient Educator only, a Physician, Nurse Practitioner or Physician Assistant signature is required. Complete the Authorization for Release of Information on the back side of the referral form. Have the person being referred sign and date the form. Provide a copy of the Community Health Network Program Guide to the person being referred and indicate the program (s) to which he/she is being referred by checking the corresponding box. Fax the form to the fax number provided. This is a secure fax. You may also scan and e-mail the referral form to
[email protected] if the e-mail can be sent in a secure format. Cindy Ariza is the Chronic Condition Resource Specialist at Department of Health. She will process the referral and contact the person being referred up to three times to assist them to attend the program. She will also forward the referral on to the contact person of the program to which the person is being referred. Progress reports will be sent from the program to the referring provider using the Referral Feedback Form and/or Provider Communication Form. If at any time you have any questions, please call Cindy Ariza at 401-222-7636.
Revised 8/2/13
COMMUNITY HEALTH NETWORK PROGRAM GUIDE Do you have a long term health condition? Are you living with chronic pain? Take control of your health! Join us and learn how to manage your condition Here is a list of programs that can help you live better. For more information or to register for a program call Cindy Ariza at the Health Department (401) 222-7636 or email
[email protected] FOR ADULTS WITH CHRONIC DISEASES AND/OR PAIN (e.g. heart disease, diabetes, COPD, arthritis) Chronic Disease Self-Management (Living Well Rhode Island) Purpose of Program: Facilitated by certified Peer Leaders, this workshop teaches people ways to manage symptoms and medications, communicate with family and doctors, handle difficult emotions, relax, eat well, exercise, and set weekly goals to improve health and lifestyles. Format: Groups sessions 2 ½ hours per week for 6 weeks. Facilitated in both English and Spanish. The Spanish version is called Tomando Control de Su Salud. Eligibility: Anyone18 years of age or older or caregivers of anyone with a chronic condition (for example: Asthma, Arthritis, Cancer, COPD, Diabetes, and/or Heart Disease) Cost: Free and incentives are provided to participants. Chronic Pain Self-Management (Living Well Rhode Island) Purpose of Program: Facilitated by certified Peer Leaders, this workshop teaches people ways to manage chronic pain by explaining how medications for chronic pain work, communicating about pain with family and doctors, and debunking myths about chronic pain. Format: Groups sessions 2 ½ hours per week for 6 weeks. Eligibility: Anyone 18 years of age or older experiencing chronic pain with or without a chronic condition. Cost: Free and incentives are provided to participants. FOR ADULTS WITH ARTHRITIS Arthritis Foundation Exercise Program Purpose of Program: Community-based, recreational exercise program that includes gentle, joint-safe exercises developed specifically for people with arthritis to help relieve stiffness, decrease arthritis pain and improve balance. The low-impact exercises can be done while sitting, standing or on the floor. Led by certified instructors. Format: Group sessions meet at various locations throughout the state and run twice a week for one hour for 6 weeks. Eligibility Requirements: People aged 18 years of age or older with arthritis. Cost: Varies by site offering program – from $0 to $45. Arthritis Foundation Walk With Ease Program Purpose of Program: The Arthritis Foundation Walk With Ease program is designed to help people living with arthritis better manage their pain and is also ideal for people without arthritis who want to make walking a regular habit. Led by a certified leader, this program has been shown to reduce pain and increase balance and walking pace. Format: Walk with Ease programs meet for 6 weeks, 3 times per week at various locations throughout the state. Eligibility Requirements: Anyone who can be on their feet for 10 minutes without increased pain. Cost: Varies and usually includes the cost of a book – from $0 to $15.
Revised 8/2/13
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FOR ADULTS WITH DIABETES Diabetes Self-Management (Living Well Rhode Island) Purpose of Program: Facilitated by certified Peer Leaders, this workshop teaches techniques to deal with symptoms of diabetes, fatigue, pain, stress, depression and anger. It also promotes exercise, proper use of medications, healthy eating, and effective communication techniques. Format: Groups sessions 2 ½ hours per week for 6 weeks. Facilitated in both English and Spanish. The Spanish version is called Tomando Control de Su Diabetes Eligibility: Anyone18 years of age or older or caregivers of anyone with diabetes. Cost: Free and incentives are provided to participants. Certified Diabetes Outpatient Educator (CDOE) Purpose of Program: CDOEs are Registered Nurses, Dietitians and Pharmacists who teach patients how to manage their glucose, blood pressure, cholesterol, medication, and nutrition. Format: Individual or group consultations in doctors’ offices, pharmacies, CDOE sites, around the state. Eligibility: People aged 18 years of age or older with diabetes. Requires a health provider order. Cost: Covered under most private health insurance plans. May require a co-pay. FOR ADULTS WITH PRE-DIABETES YMCA’s Diabetes Prevention Program Purpose of Program: This program teaches people how to lower their risk of getting Type 2 Diabetes by eating healthier, increasing physical activity and losing weight. Format: Group sessions are held once a week for 16 weeks Eligibility: Adults18 years of age or older with pre-diabetes or a person who are at risk for developing Type 2 Diabetes. Cost: Member $199; Non-Member $249, Y membership included for the duration of the core 16 sessions Financial Assistance and payment plans are available. FOR ADULTS WITH HEART DISEASE Certified Cardiovascular Disease Outpatient Educator (CVDOE) Program Purpose of Program: CVDOEs are Registered Nurses, Dietitians and Pharmacists who teach individuals how to manage their blood pressure and cholesterol, how to properly use medication, and the basics of a healthy diet. Format: Individual or group consultations in doctors’ offices, pharmacies, CDOE sites, around the state. Eligibility: People aged 18 years of age or older with cardiovascular disease with a health provider order. Cost: Covered by some health insurance plans. May require a co-pay. FOR CHILDREN WITH ASTHMA Draw a Breath Asthma Program Purpose of Program: Asthma education program for children and their parents designed to provide families with the knowledge, skills, and tools to effectively manage asthma, reduce emergency room and overnight hospital stays for asthma. The program improves child and family knowledge and confidence in managing asthma so they can take effective action towards controlling it. Format: The group-based approach creates a unique learning environment in which both children and caregivers learn from, and are motivated by, each other. Eligibility: Families with a child with asthma are eligible to take part in the program. Cost: Program services all families, regardless of their insurance status or ability to pay. Revised 8/2/13
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FOR ADULTS WHO NEED LIFESTYLE MODIFICATION Health Smart Behaviors (YMCA) Purpose of Program: Behavior change program specifically designed for African Americans which focuses on nutrition education and small goals related to healthy lifestyle changes. Format: This is an eight week program targeting the African American/Hispanic Latino population. The program works with the whole family to develop short- and long-term goals based on their household. The program combines nutrition education and physical activity. Eligibility: African American/Hispanic Latino Cost: Free YMCA’s Healthy Lifestyles Behavior Change Program Purpose of Program: Helps individuals successfully make lifestyle changes to improve their health & well-being by exploring ways to overcome barriers, stay motivated and build support networks. Format: 22-session group program. Held once a week for the first 4 sessions, and then bi-weekly for the remaining 18 sessions. Can be held at a Y or within the community. Eligibility: At least 18 years of age and ready to make behavior changes Cost: Member $199; Non-Member $249, Y membership included for duration of the program. Financial Assistance and payment plans are available. Salsa, Sabor Y Salud (YMCA) Purpose of Program: Teaches Hispanic families about the benefits of physical activity and healthy eating to make small, sustainable lifestyle changes. Families will make short- and long-term goals based on the family needs. Format: This is an eight week program that focuses on the whole family. Eligibility: Hispanic Latino Cost: Free FOR YOUTH WITH OR AT RISK FOR DISABILITIES Healthy Lifestyles for Youth with Disabilities Purpose of the Program: Presented by certified Youth Health Coaches & adult mentors, this 16-hour accessible, interactive curriculum takes participants through the self-discovery process, helps them to explore healthy life choices, and concludes with personal action plan development. Format: Workshops are held in a three full-day or two and a half hour series over a period of six to eight day time frames. A minimum of 10 participants are needed, fifteen ideal, 20 maximum. Groups benefit when peers, mentors, teachers, and others participate to provide more support. Eligibility: Transition-age youth (14-24) with special health care needs, disabilities, or who are at increased risk for a chronic physical, developmental, behavioral or emotional condition and who also require health and related services beyond what is required by children generally Cost: Free - snacks are provided and an incentive for participants who complete the program. FOR ADULT CANCER SURVIVIORS LIVESTRONG at the YMCA Purpose of Program: This cancer survivorship program is a 12- week small-group program designed for adult cancer survivors who have become de-conditioned or chronically fatigued from their treatment and/or disease, and helps them reclaim their health through improved muscle strength, cardiovascular endurance and functional ability. Format: Supervised physical activity twice per week for 12 weeks at all branches within the Greater Providence YMCA network. Eligibility: Cancer Diagnosis Cost: Free and includes free YMCA membership. Revised 8/2/13
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FOR OLDER ADULTS AT RISK FOR FALLS Matter of Balance: Managing Concerns About Falls Purpose of Program: Facilitated by Peer Leaders, group workshops teach techniques to reduce fears of falling and increase activity levels among older adults. Format: Eight two-hour sessions for a small group led by a trained facilitator. Eligibility: Adults 60 years of age and older who are ambulatory and able to problem solve Cost: Free or up to $15.00. FOR FAMILIES LIVING WITH MENTAL ILLNESS The National Alliance on Mental Illness of Rhode Island (NAMI) Purpose of Program: Offers the NAMI Family-to-Family Education course for family caregivers of individuals with mental illnesses and Inside Mental Illness, the Peer-to-Peer education program about mental illness for junior high and high school students. Format: Group and individual Eligibility: Individuals with mental illness and family members Cost: Free FOR FAMILIES WHO NEED SOCIAL SUPPORT Peer Resource Specialists Purpose of Program: Resource Specialists/Peer Navigators are trained to help people navigate healthcare systems, coordinate care, and become better advocates for families. They help with access to basic needs that often interfere with health and wellness (housing, transportation, employment, etc) Format: Resource services are offered at participating doctor’s offices, in the home, hospitals, and community agencies. Eligibility: People who could benefit from peer support and system navigation to achieve better health outcomes. Cost: Services are free for families of children with special needs. FOR PERSONS WHO WANT TO QUIT SMOKING RI Smoker’s Helpline Purpose of Program: The Rhode Island Smokers’ Helpline is the state's Quitline, which is a free evidence-based service that provides multi-session telephone counseling, provides quit tips, quit self-help materials, and referral to other quit smoking services in RI. Any individual in RI seeking to quit smoking can call 1-800-QUIT-NOW (1-800-784-8669) Format: multi-session telephone counseling Eligibility: Any RI resident Cost: Free QUiTWORKS-RI Purpose of Program: The QuitWorks-RI Program provides tobacco cessation educational training for physicians and other healthcare providers, training and support on use of fax-referral system to the Smokers’ Helpline for patients who desire to quit smoking, and follow up report on patient progress with Program. Format: Healthcare provider referral to RI Smoker’s Helpline Eligibility: Any RI resident Cost: Free Revised 8/2/13
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Frequently Asked Questions What is the Community Health Network? The Community Health Network is a collaboration of community partners and HEALTH who provide chronic disease and self-management evidence-based programs to support the medical system. The purpose is to complement practices by providing an easy way to link to resources in the community What are Chronic Disease Education and Self-Management Programs? The Chronic Disease Education and Self-Management Programs are programs developed to help your patient learn how to manage their condition and live better. There are a variety of programs available for specific or multiple conditions. Who is eligible for the programs? Ages vary by program. Adults 18 years or older living with a chronic condition, chronic pain, or even have concerns about falling are eligible for a program, even arthritis or obesity are considered chronic conditions. Our Asthma Program is for children 18 years old or younger, and their families and our Healthy Lifestyles program is for youth 14-24 years old with special needs. How much do the programs cost? Most of the programs are free or low cost. Some programs even offer incentives to the patient for completing. Please contact the specific program you are interested in for more details. How long do the programs run? Program length varies by their evidence-basis. Programs can range from a single visit lasting an hour to a 16 week program. Please refer to the program guide or contact the specific program you are interested in for more details. Why would I refer my patient to this program? All programs complement the clinical care you provide. By the end of the program, your patient will have learned how to set goals to improve their health and lifestyle, manage their symptoms and medication, work with their health care team, talk with family and doctors, relax, eat well and handle difficult emotions. By gaining these skills, your patients will become activated and engaged in their care. How does the referral process work? Referrals are easy through the Community Health Network, just fill out the referral form and fax to our secure fax line. We will follow-up with your patient to ensure they get enrolled in the program. Will I receive any feedback from the program? Yes, after the patient completes the program we will provide you with a communication form letting you know what topics were covered and how the patient did.
Encourage Participation in Self-Management Programs Chronic Disease Workshops Help Your Patients Manage Their Diseases Every day, you see the toll of chronic disease on people’s lives—the pain, the limitations, and the poor emotional health, which compromise the quality of daily life. You also recognize how hard it is for patients to follow through on recommendations for basic lifestyle changes like increasing exercise and healthy eating. But people with chronic disease can learn how to manage their symptoms and adopt healthy behaviors. Low-cost, selfmanagement workshops in your community can complement your clinical treatment and help your chronic disease patients learn to live happier, healthier lives. Your recommendation is key in helping patients with chronic diseases enroll in these vital programs.
A Low-Cost Intervention That Complements Clinical Treatment Evidence-based, self-management education programs have been proven to significantly help people with chronic diseases.1 Together with your clinical care, these programs teach participants how to exercise and eat properly, use medications appropriately, solve everyday problems, and communicate effectively with family members and health care providers— all positive life skills to enhance well-being. As a result, these interventions help participants reduce pain, depression, fear, and frustration; improve mobility and exercise; increase energy; and boost confidence in their ability to manage their condition.1
Proven Self-Management Programs That Can Make a Difference to Your Patients Two research studies, each combining the results of more than 20 evaluations, demonstrate the value of two highly successful self-management programs developed at Stanford University—the Chronic Disease Self-Management Program and the Arthritis Self-Management Program. Learn more about the results from meta-analyses of these two programs at http://www.cdc.gov/ arthritis/docs/ASMP-executive-summary.pdf. The Chronic Disease Self-Management Program is an educational workshop for people with chronic conditions (e.g., arthritis, diabetes, lung and heart disease). The Arthritis Self-Management Program is an educational workshop for people with arthritis—including osteoarthritis, fibromyalgia, rheumatoid arthritis, lupus, and others. Both programs—
Why Self-management Is Important Chronic disease is the leading cause of death and disability in the United States.2 In the United States, 1 of 2 people has at least 1 chronic disease, representing 145 million Americans. Twenty-eight percent of all Americans have two or more chronic conditions.2 Nationally, chronic diseases account for 75% of the $2 trillion spent on health care each year in the United States.2 Fifty million Americans have been diagnosed with arthritis,3 the most common cause of disability.4 The medical costs for treating arthritis are at least $81 billion per year.5 Helping people with chronic disease learn to better manage their conditions will help reduce the personal and societal burden of chronic diseases in the United States.
33 Are designed to be taught in a community setting, such as a senior center, church, library, or hospital.
Significant Effect Sizes for CDSMP Outcomes at 4-6 and 12 months Follow-up Many of the Effects of CDSMP Persist at 12-Month Follow-Up Energy
33 Are offered as a 2 ½ -hour per week workshop for 6 weeks.
Fatigue Self-Rated Health
33 Are led by trained leaders who have chronic conditions themselves, and who follow a structured leader protocol. 33 Help participants learn how to take control of their chronic disease.
Pain Self-Efficacy (SE) Health Distress Depression Aerobic Exercise Cognitive Symptoms Management
33 Encourage interaction and mutual problem-solving and support.
Communication with Physician -0.4 -0.3 -0.2 -0.1
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Effect Sizes
33 Are designed to complement clinical treatment and diseasespecific education programs.
4–6 months
12 months
33 Are available in English and Spanish. The Chronic Disease Self-Management Program also teaches skills to people managing multiple chronic conditions. Learn more about these two Stanford University programs at http://patienteducation.stanford.edu/programs.
Help Your Patients Gain the Skills and Confidence to Manage Their Chronic Disease You play an important role in facilitating participation in these proven, low-cost, convenient workshops. Research shows that, with a recommendation from a health care provider like you, a patient is much more likely to attend
Participants Applaud Benefits of Self-Help Workshops “They taught us to focus on what we can do and not on what we can’t do.” “The pain doesn’t go away, but you learn to manage the pain instead of the pain managing you.” “Now I can work better with my doctor to manage my symptoms.” “I know the things to do, this helps my motivation to get it done.” “The progress is due to the positive class support.”
a self-management workshop. Help people with chronic diseases manage their symptoms, make lifestyle changes, and live the fullest life possible. Incorporate self-management workshops referrals in your comprehensive approach to chronic disease. Recommend the Chronic Disease SelfManagement Program and the Arthritis SelfManagement Program to your patients. Locate programs in your area at http://restartliving.org. 1. 2. 3. 4. 5.
h ttp://www.cdc.gov/arthritis/docs/ASMP-executive-summary.pdf. http://www.rwjf.org/files/research/50968chronic.care.chartbook.pdf. MMWR 2010;59(39):1261–1265. MMWR 2009;58(16):421-426. MMWR 2007;56(01):4-7.
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Chronic Self-Management Programs Disease
Help Your Patients Take Charge
Managing a chronic disease can be complex and frustrating—for you and your patients. Give them the tools they need to improve their health. Recommend a self-management education or physical activity intervention and help your patients take charge.
Current medical treatment options may not always give your patients the relief they’re looking for, or they may have trouble following your treatment recommendations. Evidence suggests that nonpharmacological treatments are an important part of chronic disease management. The Centers for Disease Control and Prevention (CDC) Arthritis Program has identified a number of self-management education and physical activity interventions proven effective for people with chronic conditions, including arthritis, diabetes, heart disease, and lung disease. These interventions can reduce symptoms, give your patients the confidence to manage their condition, and improve their quality of life.
The self-management education and physical activity interventions supported by the CDC Arthritis Program are: t Credible. They were designed by reputable organizations like Stanford University, the University of Washington, and the Arthritis Foundation. Classes are taught by trained and certified instructors. t Low-cost. Self-management education courses typically cost about $25–$40. Physical activity classes cost $1–$4 per session. t Convenient. Classes are offered at convenient locations in your community. Self-management education courses require about a 2–2½ hour time commitment per week for 6–8 weeks. Physical activity classes meet one to three times per week for 8–12 weeks or on an ongoing basis.
National Center for Chronic Disease Prevention and Health Promotion Division of Population Health
t Almost 1 out of every 2 adults in the U.S. has at least one chronic disease.1 More than 1 in 4 adults have two or more chronic diseases.2 t For about one-fourth of these people, their condition limits their daily activities.1 t The leading cause of disability is arthritis. More than 50 million American adults have doctordiagnosed arthritis.3 t Your recommendation is important. People are more than 18 times as likely to participate in a selfmanagement education intervention if their health care provider recommends it.4 1
www.cdc.gov/chronicdisease/overview www.rwjf.org/pr/product.jsp?id=50968 3 www.cdc.gov/arthritis/media/quickstats.htm 4 Arthritis and Rheumatism. 2007;56(9):S307–308. 2
Chronic Self-Management Programs Disease
Provide instruction on day-to-day strategies for managing and coping with chronic health conditions, including: t Techniques to deal with pain, fatigue, and physical limitations t Appropriate exercise and medication use t Effective communication with family, friends, and physicians t Proper nutrition Are offered in English and Spanish
t Brady TJ, Jernick SL, Hootman JM, et al. Public health interventions for arthritis: expanding the toolbox of evidence-based interventions. Journal of Women’s Health. 2009;18(12):1905–1917. t Quick stats on arthritis: www.cdc.gov/arthritis/media/ quickstats.htm t Descriptions of specific interventions: www.cdc.gov/arthritis/ interventions.htm t CDC publications by topic: www.cdc.gov/arthritis/ publications/topics.htm
Help Your Patients Take Charge
Teach a range of exercises that can be modified for different skill and disability levels, including: t Balancing and stretching techniques t Endurance and strength training t Low-impact aerobics Are designed to improve flexibility, joint range of motion, balance, endurance, and strength May also teach behavioral skills like goal-setting, problem-solving, and overcoming barriers
Evidence from clinical trials and program evaluations shows that the self-management education and physical activity interventions supported by the CDC Arthritis Program can: t Reduce pain and fatigue t Improve self-rated health t Improve range of motion t Increase physical activity t Elevate mood t Improve psychological well-being t Increase participants’ confidence in their ability to manage their health Studies have found that the effects of these interventions last well after the last class—up to 12 months or more. Improvements in symptoms and quality of life can help your patients be more effective partners in their health care.
Community Health Network Referral Feedback Form Date:
Patient Information: Patient Name: Patient DOB: Program(s):
Referral Update: Patient did not return calls/messages after three attempts Patient is undecided at this time Patient is considering a future class Patient has declined participation at this time Patient enrolled in program Referral received, patient contacted on currently coordinating with program for enrollment. Notes:________________________________________________________ _____________________________________________________________ _____________________________________________________________ If additional follow-up is requested or patient contact information has changed please contact Cindy Ariza. Cindy Ariza Patient Navigator Community Health Network 401-222-7636 401-222-4418-fax
[email protected]
COMMUNITY HEALTH NETWORK Provider Communication Form
To: ___________________________________________________________________________________________________________ Provider Name
Fax No._______________________________________________________________________________________________________ Thank you for referring____________________________________________________________________________________ Name of person referred
to_________________________________________________________________________ Date(s)____________________________________ Name of Program
The following checked topics were covered:
Diabetes Care Topics Blood Glucose Goals/A1c
Asthma Care Topics How to Use the Asthma Care Plan
Other Topics Blood Pressure Control
Carbohydrate Counting
Asthma Trigger Avoidance
Cholesterol Control
Prevention & Treatment of hypoand hyperglycemia
Asthma-Proofing the Home
Falls Prevention
Insulin Administration and Storage
Healthy Lifestyle Topics
Pain Management
Screenings to Prevent the Complications of Diabetes
Physical Activity Plan
Medication Adherence and Management
Sick Day Management
Healthy Eating – Menu planning and portion control
Diabetes Prevention
Glucometer Use
Label Reading
Peer Support
Foot checks
Weight Management Plan
Resource Navigation
Insulin Pump Management
Tobacco cessation
Adolescent Transition
Effect of Activity on Blood Glucose
Stress Management - Healthy Coping
Other:
Self-Management Goal: ________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ____________________________________________________________________________________ Print name & title of educator/facilitator
______________________________ Phone No.
____________________________________________________________________________________ Educator/Facilitator Signature
_______________________________ Date
Revised 8/2/13
