Ambulatory Care Sensitive Conditions

User Guide

The toolkit is composed of three sections:

  • Hospital and Health System Resources – for senior management, senior leaders for quality, clinic managers, nurse managers, key physician leaders, risk managers and human resources directors, this section includes guides, fact sheets, and resources supporting treatment of ambulatory care sensitive conditions (ACSC).
  • Clinician Resources – includes clinical evidence for management of specific ACSCs, frequently asked questions and a report on the impact of integrated care on preventing hospitalization.
  • Patient Resources – includes action plans, frequently asked questions and resources for patients on how to best engage in their care and prevent hospitalizations for ACSCs.

Hospital and Health System Resources

Ambulatory Sensitive Condition Admissions: Opportunities and Challenges Webinar
This free educational webinar shares a case example of how reducing preventable inpatient admissions for ACSCs can improve care and lower costs. The webinar features Dana L. Gilbert, chief operating officer and Sharon Rudnick, vice president Outpatient Enterprise Care Management of Advocate Physician Partners (Illinois) sharing their experiences in reducing admissions for ACSCs. To view, click here »

Guide to Prevention Quality Indicators: Hospital Admission for Ambulatory Care Sensitive Conditions
This guide, developed by AHRQ, provides information on Prevention Quality Indicators (PQIs), which are a set of measures that can be used with hospital inpatient discharge data to identify quality of care for ACSCs. To download, click here »

Million Hearts® Begins with You Infographic and Fact Sheet
Million Hearts® is a national initiative that was launched by the Department of Health and Human Services in September 2011 to prevent 1 million heart attacks and strokes by 2017. To download, click here »

TeamSTEPPS™: Team Strategies and Tools to Enhance Performance and Patient Safety
This article, included in Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools), describes the TeamSTEPPS program developed by the Department of Defense and AHRQ. TeamSTEPPS integrates teamwork into practice to improve the quality, safety and the efficiency of health care. To download, click here »

Re-Engineered Discharge (RED) Toolkit
Boston University Medical Center (BUMC) developed and tested methods of improving the discharge process, which they called the Re-Engineered Discharge (RED). AHRQ contracted with BUMC to develop this toolkit to assist hospitals in replicating RED. Tools include steps on how to begin implementation of RED, deliver and then monitor outcomes. To download, click here »

Selections from Guide to Patient and Family Engagement in Hospital Quality and Safety
AHRQ developed this evidence-based resource to help hospitals work as partners with patients and families to improve quality and safety. Included here are three resources from the “Information to Help Hospitals Get Started” section, addressing how the guide can benefit hospitals, four broad steps to start the process of using the strategies and tools found in the guide as well as specific suggestions on how hospital and health system leaders can foster a supportive environment for patients and their families. To download, click here »

Hospital Admissions and Costs for Potentially Preventable Conditions in Adults, 2006
This fact sheet from ACP shows at a glance hospital costs for potentially preventable conditions. To download, click here »

More May Be Better: Evidence of a Negative Relationship between Physician Supply and Hospitalization for Ambulatory Care Sensitive Conditions
Using data compiled by AHRQ, this Health Services Research article finds greater physician supply is associated with lower ACSC rates in all age groups. To download, click here »

How is a Shortage of Primary Care Physicians Affecting the Quality and Cost of Medical Care?
This white paper, released by ACP, reviews more than 100 studies over a 20-year period finding the critical importance of primary care in providing patients with better outcomes at lower cost, and the urgency of the need to prevent shortages of primary care physicians. To download, click here »

Keeping Children Out Of Hospitals: Parents’ and Physicians’ Perspectives on How Pediatric Hospitalizations for Ambulatory Care Sensitive Conditions Can Be Avoided
Published in Pediatrics, this article finds many “pediatric hospitalizations might be avoided if parents and children were better educated about the child’s condition, medications, the need for follow-up care, and the importance of avoiding known disease triggers. Direct assessment by parents and physicians of hospitalized children can be an informative way to examine the proportion of avoidable pediatric hospitalizations and how they can be prevented.” To download, click here »

Clinician Resources

Strategies for Reducing Potentially Avoidable Hospitalizations for Ambulatory Care Sensitive Conditions
Published in Annals of Family Medicine, this article finds “primary care physicians rated a significant proportion of hospitalizations for ACSC to be potentially preventable” and offers strategies aimed at reducing the number of avoidable hospitalization which in turn increases quality of care and decreases health care expenditures. To download, click here »

High-Value Care Coordination Toolkit
Created by ACP’s Council of Subspecialty Societies (CSS) and patient advocacy groups, the High-Value Care Coordination toolkit provides resources to facilitate more effective and patient-centered communication between primary care and subspecialist doctors. The toolkit includes data sets, checklists, a guide for facilitating discussion with patients and care coordination agreements. To view, click here »

High-Value, Cost-Conscious Health Care: Concepts for Clinicians to Evaluate the Benefits, Harms, and Costs of Medical Interventions
This article, published in Annals of Internal Medicine, discusses three key concepts for understanding how to assess the value of health care interventions. To download, click here »

Asthma’s Impact on the Nation
Frequently asked questions and statistics from the CDC National Asthma Control Program. To download, click here »

Potentially Preventable Hospitalizations – United States, 2001–2009
This CDC Morbidity and Mortality Weekly Report (MMWR) discusses reducing hospitalization rates as a key to controlling health care costs. For many chronic conditions, inpatient costs are the dominant expense. Using diabetes as an example, approximately half of the expenditures of persons with diabetes are spent on hospital inpatient care, compared with 12 percent spent on diabetes medications and supplies and 9 percent spent on physician office visits. The CDC has published articles on preventable hospitalizations for specific conditions, including:

Reducing Readmissions for Congestive Heart Failure
In this American Family Physician article, authors Robert E. Hoyt, CAPT, MC, USN and Lester Shawn Bowling, LTCR, MC, USN address “hospital admission for congestive heart failure [which] is extremely common and quite expensive, although it is frequently preventable.” To download, click here »

Diagnosis and Management of Community-Acquired Pneumonia in Adults
Authors Richard R. Watkins, MD, MS and Tracy L. Lemonovich, MD discuss studies and guidelines for community-acquired pneumonia in adults published since the 2006 American Family Physician review of the topic. To download, click here »

Gastroenteritis in Children
A two-part article by authors Catherine A. Churgay, MD and Zahra Aftab, MD published in American Family Physician, discusses diagnosis (Part 1) as well as prevention and management (Part 2). To download, click here »

Developed by ACP, HEALTH TiPS are meant to improve the clinician-patient encounter by facilitating a focus on the key information needed to manage each health condition. HEALTH TiPS can be downloaded in an electronic format, or as a pad of 50 two-sided 4”x6” tear-off sheets. Conditions HEALTH TiPS cover include:

Patient Resources

Choosing a Type 2 Diabetes Drug
Lifestyle changes alone can sometimes lower blood sugar levels enough that drugs aren’t needed to treat Type 2 Diabetes. And when they are, the best first choice usually isn’t one of the newer, heavily advertised ones on the market. One of ACP’s High-Value Care resources in collaboration with Consumer Reports derived from ACP’s evidence-based clinical practice recommendations published in Annals of Internal Medicine, this article helps patients understand benefits, harms and costs of treatments for Type 2 Diabetes. To download, click here »

CDC’s Take Charge of Your Diabetes
This book helps patients take important steps to prevent problems caused by diabetes, understand how to work with a health care team to prevent problems, why it is important to get blood glucose and blood pressure closer to normal and how to utilize resources in the community to prevent problems. To download, click here »

Asthma Action Plan
From the National Heart, Lung and Blood Institute, this tool includes a guide on avoiding asthma triggers and daily treatment, such as what kind of medicines to take and when to take them. The plan describes how to control asthma long term and how to handle worsening asthma or attacks as well as explains when to call the doctor or go to the emergency room. To download, click here »

Living with COPD: An Everyday Guide for You and Your Family
This self-management guide developed by ACP covers areas such as living well with COPD, getting the most out of medicines, becoming more active, planning for when breathing gets worse and smoking cessation. To download, click here »

Caring for Your Heart: An Everyday Guide for You and Your Family
This ACP guide informs patients how eat right, be active, get the most from medications prescribed, understand feelings, respond to chest pains and free themselves from smoking. To download, click here »

CDC’s High Blood Pressure FAQ
Frequently asked questions such as what blood pressure levels are healthy, and tips to maintain normal levels, avoiding hospitalization. To download, click here »

How to Stay Out of the Hospital if You Have Congestive Heart Failure
This patient information handout, written by the authors of Reducing Readmissions for Congestive Heart Failure found in AAFP’s American Family Physician, answers frequently asked questions. To download, click here »

Imaging Tests for Low Back Pain
One of ACP’s High-Value Care resources in collaboration with Consumer Reports derived from ACP’s evidence-based clinical practice recommendations published in Annals of Internal Medicine, this article helps patients understand benefits, harms, and costs of tests for low back pain. To download, click here »