Intervention	Intensity	Method
Assess health confidence	Low	Ask patient directly and record as structured data in electronic health record. (See visual aid and additional free health assessment resources at https://howsyourhealth.org.)
Define patient as belonging to “at-risk” population	Low	Identify patients with health confidence scores of less than 8.
Label chart of “at-risk” patients	Low	Flag patient record to identify at-risk patients as part of a cohort requiring enhanced services.
Perform medication reconciliation	Moderate	Perform medication reconciliation in person or by telephone regularly and after any hospital contacts.
Assess medication adherence	Moderate	Ask questions based on Morisky Medication Adherence Scale;1 record answers in structured data fields.
Perform enhanced previsit preparation	Moderate	Use a team approach involving nurses, care coordinators, medical assistants, etc.; ask about patient's goals for visit.
Engage office staff in focused, intensive outpatient care	Moderate	Create vision: What does improving health care look like?
Standardize panel management	Moderate	Develop flow maps detailing the care management steps to be performed during visits for patients with chronic diseases.
Use motivational interviewing	Moderate – High	Incorporate into patient interactions where appropriate.
Provide focused transitional care management	High	Contact all patients within 48 hours of discharge from emergency department or inpatient care.
Provide in-office care coordinator visit	High	Schedule for 15 minutes prior to office visit with provider.
Provide intensive chronic disease management	High	For example, implement asthma action plans, PHQ-9, and patient education, and refer to mental health resources as needed.