Education > Best Practices

Best Practice Intervention Packages (BPIPs)

Please note: All guidelines and recommendations are to be used along with physician/clinician judgment and treatment based on individual patient’s unique needs and circumstances.

Cardiovascular Smoking Effects & Cessation Video BPIPs

Patient and clinician videos related to the cardiovascular effects of smoking and assistance with quitting smoking. 
  • Smoking and Your Heart
  • How to Quit Smoking
  • Smoking Cessation with Your Patients

Cardiovascular Blood Pressure Control Video BPIPs

Patient videos provide additional patient education on interventions to manage blood pressure.
  • Blood Pressure Medication Management
  • How to Check My Own Blood Pressure

Cardiovascular Health for At-Risk Populations

This focused package identifies specific risks for certain at-risk populations including racial/ethnic, gender, health literacy barriers, and regional variances. Strategies to address barriers and tools/resources are provided.  

Cardiovascular Risk Factors Video BPIPs

Educational videos, evidence-based tools, and activities to help patients and clinicians understand the impact of a variety of cardiovascular risk factors
  • Risks & Signs of Heart Attack & Stroke
  • Race & Ethnicity Cardiovascular Risk Factors
  • Diabetes & Your Heart

Cardiovascular Lifestyle Management Video BPIPs

Educational clinician videos and evidence-based patient tools that promote the six lifestyle modifications recommended to prevent hypertension
  • Lifestyle Modifications part 1: Weight Reduction, DASH Eating Plan, and Sodium Reduction
  • Lifestyle Modifications part 2: Physical Activity, Alcohol Moderation, and Smoking Cessation

Fundamental Focus: Blood Pressure Control & Smoking Cessation

This fundamental BPIP focuses on two key evidence-based strategies to reduce heart attacks and strokes: blood pressure control and smoking cessation. This package will serve as a 'refresher' and is intended for use by clinicians and leaders. For more in-depth content, please refer to the primary Cardiovascular Health Part 1 (blood pressure control) and Part 2 (smoking cessation) BPIPs below.

Disease Management: Heart Failure (Focused)

The Focused BPIP on Disease Management: Heart Failure explains why heart failure is a national and community concern and provides free resources for clinicians and patients.

Disease Management: Diabetes

The Disease Management: Diabetes BPIP primarily addresses type 2 diabetes. Latest statistics and information are included, but tools and resources for both clinicians and patients comprise the majority of the package. This BPIP was last updated on May 2, 2016.

Cardiovascular Health Part 2

The Cardiovascular Health Part 2 BPIP focuses on improving cholesterol screenings and actions to reduce cardiovascular risk, as well as tools and resources for clinicians to help patients stop smoking. This package has been revised to include industry guidelines for cholesterol management published in 2013.

Cardiovascular Health Part 1

The Cardiovascular Health Part 1 BPIP focuses on the evidence-based practices for using appropriate aspirin or antiplatelet therapy with patients who need it, as well as assessments and strategies to assist patients with controlling their blood pressure to prevent heart attacks and strokes. This package has been revised to include new industry guidelines, algorithms, and protocols for hypertension management released in 2013.

Immunization and Infection Prevention

The Immunization and Infection Prevention BPIP is designed to guide leaders to ensure agency immunization and infection prevention programs are evidence-based and focus on patient and employee safety. This BPIP will assist leaders to develop strategies to improve immunizations for both patients and employees. Immunization and infection prevention tools and Web links on current guidance and standards are included in the BPIP. This package has been revised to include industry guidelines as of 2015.

Medication Management (Focused)

Focused BPIPs are succinct intervention packages designed to support or enhance best practices. The patient tools in the Focused BPIP on Medication Management are designed to be patient friendly to improve health literacy. 

Underserved Populations (UP)

The UP BPIP provides agencies foundational information on significant topics that are affecting healthcare quality and costs across all settings, including home health.  The main topics in this package are related to the following:
  • Underserved 
  • Dual-Eligible
  • Health Disparities
  • Small Non-Profit Home Health Agencies
The issues and barriers associated with these topics are enormous and affect day-to-day care for our patients. The UP BPIP is intended to begin a dialogue and awareness at some agencies, while other agencies will be adding improvement efforts to overcome the barriers for all patients to receive equitable healthcare.

Patient Self-Management (Focused)

All chronic care patients self-manage, but health care professionals have an opportunity to advance patient self-management through self-management support. The Patient Self-Management BPIP is offered in the new "focused" format, providing a more succinct intervention package that is designed to support or enhance best practices. The Focused BPIP provides tools and resources that are easy to understand and simple to implement. This BPIP was updated on February 1, 2016.

Fundamentals of Reducing Hospitalizations

The Fundamentals of Reducing Hospitalizations BPIP (released July 1, 2016) provides an overview of reducing avoidable hospitalizations including many of the Centers for Medicare & Medicaid Services (CMS) initiatives. Key intervention strategies and tools are highlighted. There are several other supporting resources including:
  • Patient multimedia module on self-assessment of hospitalization risk
  • Clinician podcast on care transitions
  • Home health agency success stories

Improving Management of Oral Medications

In the Improving Management of Oral Medications BPIP, you will find evidence-based tips for both patients and staff education to assist in improving your patients' management of their medications.

The Improving Management of Oral Medications BPIP includes a foundational and advanced review of medication reconciliation, simplification, adherence, as well as planning tools. Some of these tools include:
  • Personal Health Record
  • Potentially Inappropriate Medications (PIM) for Older Adults
  • OASIS M2020 Quick Guide
  • A pharmacist's perspective
  • Organizational culture tips on changing the negative thought process from "not much we can do" to "what can we do to improve this patient's quality of life?"

Fall Prevention

Falling is a potentially avoidable event which can change a person's life. In the Fall Prevention BPIP, you'll find evidence-based tips for both patients and staff education to assist in reducing your patients' risk for falling.

The Fall Prevention BPIP also includes a foundational and advanced review of in-home patient safety. Examples of tools included are:
  • Fall Risk Assessment
  • TUG (Timed Up and Go)
  • Medication Simplification
  • "Pull-Out" Focus Sections
  • Organizational Culture Section exploring the impact your organizational culture has on the reporting or "under reporting" of falls in the home
  • Links to the program "Fall Prevention Awareness: Enhanced Training for Home Health Aides"

Cross Settings I

As a patient moves through the continuum of health care, opportunities for mistakes are more prevalent.  Not only does this potentially decrease the quality of the patient’s life, it also costs the United States millions of dollars each year in unnecessary health care costs.  In the Cross Settings I BPIP, you will find evidence-based tips for both patient and staff education to assist in reducing this risk while providing seamless care transitions in your community.
The Cross Settings I BPIP also includes a foundational and advanced review of Transitional Care and Coaching models.  Examples of specific tools and resources included in this BPIP are:

  • Discharge and Transfer Summary Notes
  • Links and discussion to Project RED (Project Re-Engineered Discharge) and BOOST (Better Outcomes for Older adults through Safe Transitions)
  • Teach Back Nurse Practice Exercises and Medication Cards
  • Tools for phone monitoring and assessment (telehealth)

Cross Settings II

Although most chronic disease processes do not change, the tools which support the education of patients, families and staff do.  In the Cross Settings II BPIP, you will find the most current evidence-based tools to educate your population on disease management in diabetes, heart failure, COPD and palliative care as well as the Chronic Care Model (CCM).
The Cross Settings II BPIP also includes a foundational and advanced review of self-care management and telehealth
Examples of specific tools and resources included in this BPIP are:
  • Home Telehealth Disease Management Series including COPD, HF, & Diabetes
  • “My Action Plan” in Spanish, Chinese, and English
  • “Personal Health Record”

Cross Settings III

Methods of health care delivery in this country are changing rapidly.  In the Cross Settings III BPIP, you will find innovative ideas to help prepare for health care changes.
The Cross Settings III BPIP also includes a foundational and advance review of:

  • Innovation Center
  • Affordable Care Act
  • Patient-Centered Medical Homes (PCMH)
  • Accountable Care Organizations