Partners CAP Self-Care Management Tools

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Table of Contents
History of the Community Access Program (CAP)

Diabetes
Health Disparities Measures & Goals for Diabetes (Link)
Diabetes Goal Setting Contract
    Patient Agreement to One Diabetes Goal (MS Word)
Diabetes Patient Questionnaire (MS Word)
Diabetes Self-Management (MS Word)
Diabetes Zones for Self-Management
    ASelf-Care Stoplight (Green, Yellow, Red) Guide (MS Word)
Patient Guide for Diabetes Management (MS Word)
Tips for Diabetes Control (MS Word)
New Year Patient Letter (MS Word)

Asthma
Health Disparities Measures & Goals for Asthma (Link)
Asthma Severity Diagnosis
    Asthma Assessment Flow Sheet (MS Word)
Asthma Action Plan
    A Self-Care Stoplight (Green, Yellow, Red) Guide Asthma Questionnaire (MS Word)
Asthma Questionnaire
    How do YOU think your asthma is? (MS Word)
Asthma Medical Record Templates for Initial and Follow-up Visit
    Asthma Notes: Initial Assessment (2 pages) (MS Word)
Asthma Notes: - Follow-up Assessment (MS Word)
Asthma Notes: - Asthma Progress Note (MS Word)

Depression
Health Disparities Measures and Goals for Depression (Link)
Depression/Mental Health Flow Sheet (MS Word)
Depression Self-Care Survey
   Introduction & Patient Questionnaire (2 pages)
       Nine Symptom Checklist(MS Word)
Process for Managing Depression (MS Word)
Self-care Action Plan (two-sided tri-fold) (MS Word)
What Is Depression? (MS Word)
What you should know about your medication (MS Word)

Hypertension/Cardio-Vascular
Health Disparities Measures & Goals (Link)
Cardiovascular Self-Management (Adobe Acrobat)
Tips for Blood Pressure Control (Adobe Acrobat)

Blank Forms
HIPAA Authorization Form (MS Word)
Instructions - Application for Primary Care Benefits
    Application for Primary Care Benefits (MS Word)
Instructions - Application for Re-Enrollment for Primary Care Benefits
Alternative Application for Health Benefits (MS Word)
Patient Financial Statement  Page 1   Page 2
Instructions - Health History
    Health History scan form(Adobe Acrobat) * See note at top of page
Instructions - Adult Health Schedule
    Adult Health Schedule (MS Excel)
Instructions - Data Sheet
    Data sheet (Adobe Acrobat) * See note at top of page
Partners CAP Member Satisfaction Survey (Adobe Acrobat) * See note at top of page
CAP Health Survey (SF8) (Adobe Acrobat) * See note at top of page

Measurement & Evaluation
Strategy
Key Measures
Comparison Sources
Preventive Measures & Screening
LINKS

Preventive Information
Alcohol Facts (MS Word)
When Smokers Quit (MS Word)