Resources
Program Management & Implementation

• This section includes materials useful to program design, implementation and overall program management. Materials include sample interview scripts, tailored practice guidelines,  curricula and lesson plans, clinical flow sheets and documentation forms, sample policies and procedures, topic-specific lesson plans, curricula and more, all organized by topic area.

Community Health Workers
Community Health Worker Agreement (Open Door Health Center)
Community Health Worker Patient Phone Interview Script (Open Door Health Center)
Community Health Worker Roles and Responsibilities (Open Door Health Center)
Depression Referral Letter (La Clinica de La Raza)

Lay Health Educator Manual (MaineGeneral Health)

Move More Replication Kit (MaineGeneral Health)
Promotora Policies and Procedures (Gateway Community Health Center)

General Administration
Barriers Identified for Diabetes Self Management (Open Door Health Center)
Barriers to Diabetes Self Management (Minneapolis American Indian Center)

Case Management Check-in Form (Dept. of Family and Comm. Health/Marshall University)
Case Management Intake Form (Minneapolis American Indian Center)

Certified Diabetes Educator Guidelines (Gateway Community Health Center)
Community Action Plan for Self Management (Minneapolis American Indian Center)
Community Health Worker Agreement (Open Door Health Center)
Community Health Worker Patient Phone Interview Script (Open Door Health Center)
Community Health Worker Roles and Responsibilities (Open Door Health Center)
Depression Referral Letter (La Clinica de La Raza)
Depression Screening and Follow Up Flow Chart (Gateway Community Health Center)
Diabetes Clinical Form (Minneapolis American Indian Center)
Diabetes Provider Visit Form (St. Peter Family Medicine Residency)
Diabetes Visit Protocol (Minneapolis American Indian Center)
Goal Setting Contact Sheet (La Clinica de La Raza)
Group Medical Visit Consent Form (St. Peter Family Medicine Residency)

Guide to Stages of Change Interventions English (La Clinica de La Raza)

Guide to Stages of Change Interventions Spanish (La Clinica de La Raza)

Guide to Successful Holistic Program Implementation (Minneapolis American Indian Center)

Holistic Program Evaluation Tool (Minneapolis American Indian Center)
Informed Consent Form English (Gateway Community Health Center)
Informed Consent Form Spanish (Gateway Community Health Center)

Lay Health Educator Manual (MaineGeneral Health)

Move More Replication Kit (MaineGeneral Health)

Patient Flow Sheet (Community Health Center)

Patient Success Stories Interview Form (Gateway Community Health Center)

Policies and Procedures for Referring Patients (Gateway Community Health Center)

Program Flow Sheet (Richland County Health Department)

Program Intake Form (Galveston County Health District)

Promotora Policies and Procedures (Gateway Community Health Center)
Recording Sheet (Gateway Community Health Center)
Referral Form (Gateway Community Health Center)

Self Management Call Back Cards (St. Peter Family Medicine Residency)

Self Management Goal Tracking Sheet (Community Health Center)
Topic Form (Community Health Center)

TTM Practical Guide for Providers (La Clinica de La Raza)
TTM Provider Cards (St. Peter Family Medicine Residency)
Type II Diabetes Standing Orders (MA Planned Visit) (St. Peter Family Medicine Residency)

Goal Setting

Goal Setting Contact Sheet (La Clinica de La Raza)
Goal Setting Form (Gateway Community Health Center)
Goal Tracking Form (Galveston County Health District)

Guide to Stages of Change Interventions English (La Clinica de La Raza)

Guide to Stages of Change Interventions Spanish (La Clinica de La Raza)

Self Management Call Back Cards (St. Peter Family Medicine Residency)

Self Management Goal Quality Poster (St. Peter Family Medicine Residency)
Self Management Goal Tracking Sheet (Community Health Center)

Take Action: My Action Plan Lesson Plan and Student Material (Galveston County Health District)

Take Action: Ready for Change Lesson Plan, Student Material and Food Diary and Behavior Worksheets (Galveston County Health District)

Healthy Coping
Depression Referral Letter (La Clinica de La Raza)
Depression Screening and Follow Up Flow Chart (Gateway Community Health Center)

Take Action: Coping with Diabetes Lesson Plan, Student Material and Denial and Anger Worksheets (Galveston County Health District)

Take Action: Stress Lesson Plan, Student Material and Worksheets 1 and 2 (Galveston County Health District)

Healthy Eating

Take Action: Nutrition Lesson Plan, Student Material and Meal Plan, Pyramid, Balance and Portion Size Worksheets (Galveston County Health District)

Whisking Your Way to Health Lesson Plans (Evaluating Recipes, Using Labels and Planning Meals, Cooking, Portion Sizes, and Shopping), Evaluation Form and Sample Recipes (Galveston County Health District)

Linking to Quality Clinical Care
Community Action Plan for Self Management (Minneapolis American Indian Center)
Referral Form (Gateway Community Health Center)

Multiple Self Management Behaviors
6-Session Diabetes Self Management Curriculum (text) (Community Health Center)
6-Session Diabetes Self Management Curriculum (slides, sessions 2-6) (Community Health Center)

6-Session Diabetes Self Management Curriculum Spanish (slides) (Community Health Center)
Barriers Identified for Diabetes Self Management (Open Door Health Center)
Barriers to Diabetes Self Management (Minneapolis American Indian Center)

Case Management Check-in Form (Dept. of Family and Comm. Health/Marshall University)
Case Management Intake Form (Minneapolis American Indian Center)

Certified Diabetes Educator Guidelines (Gateway Community Health Center)

Diabetes and the Family Curriculum (Campesinos Sin Fronteras)
Diabetes Clinical Form (Minneapolis American Indian Center)
Diabetes Provider Visit Form (St. Peter Family Medicine Residency)
Goal Setting Contact Sheet (La Clinica de La Raza)
Goal Setting Form (Gateway Community Health Center)

Program Intake Form (Galveston County Health District)
Self Management Goal Tracking Sheet (Community Health Center)

Take Action: Managing Blood Sugar Lesson Plan, Student Material and Log (Galveston County Health District)

Take Action: Managing Complications Lesson Plan and Student Material (Galveston County Health District)

Take Action: Managing Medication Lesson Plan, Student Material (Insulin) and Student Material (Oral) (Galveston County Health District)

Take Action: Sick Days Lesson Plan, Student Material, Workbook and Record Worksheet (Galveston County Health District)

Take Action: What is Diabetes Lesson Plan, Student Material, Provider Questions, and Record Worksheet (Galveston County Health District)
Topic Form (Community Health Center)

Type II Diabetes Standing Orders (MA Planned Visit) (St. Peter Family Medicine Residency)

Weekly Diabetes Class Curriculum Session 1 and Session 2 (Open Door Health Center)

Partnership
Community Action Plan for Self Management (Minneapolis American Indian Center)

Guide to Successful Holistic Program Implementation (Minneapolis American Indian Center)

Physical Activity
Exercise Prescription Release Form (Minneapolis American Indian Center)

Lay Health Educator Manual (MaineGeneral Health)

Move More Replication Kit (MaineGeneral Health)

Take Action: Exercise Lesson Plan, Student Material and Worksheet (Galveston County Health District)

Systems to Support Organizational Capacity

Certified Diabetes Educator Guidelines (Gateway Community Health Center)

Community Health Worker Agreement (Open Door Health Center)
Community Health Worker Roles and Responsibilities (Open Door Health Center)
Depression Screening and Follow Up Flow Chart (Gateway Community Health Center)
Diabetes Visit Protocol (Minneapolis American Indian Center)
Patient Flow Sheet (Community Health Center)

Policies and Procedures for Referring Patients (Gateway Community Health Center)

Program Flow Sheet (Richland County Health Department)

Promotora Policies and Procedures (Gateway Community Health Center)

Self Management Goal Guide (Galveston County Health District)

TTM Practical Guide for Providers (La Clinica de La Raza)