# data[].attributes.headline
Teach patient how to measure and record blood pressure at home

# data[].attributes.subject
Teach patient how to measure and record blood pressure at home

# data[].attributes.headline
Teach patient how to measure and record blood glucose readings at home

# data[].attributes.subject
Teach patient how to measure and record blood glucose readings at home

# data[].attributes.headline
Teach patient how to measure and record blood glucose monitoring

# data[].attributes.subject
Teach patient how to measure and record blood glucose monitoring

# data[].attributes.headline
E-order Diabetic Eye and Foot screenings

# data[].attributes.subject
E-order Diabetic Eye and Foot screenings

# data[].attributes.headline
Teach patient how to measure and record blood pressure at home

# data[].attributes.subject
Teach patient how to measure and record blood pressure at home

# data[].attributes.headline
Recall defaulters (no show) and reschedule appointments

# data[].attributes.subject
Recall defaulters (no show) and reschedule appointments

# data[].attributes.headline
Refill medications for well controlled chronic patients 

# data[].attributes.subject
Refill medications for well controlled chronic patients 

# data[].attributes.headline
Counsel patients on challenges managing their chronic condition(s) 

# data[].attributes.subject
Counsel patients on challenges managing their chronic condition(s) 

# data[].attributes.headline
Screen patients who require vaccinations 

# data[].attributes.subject
Screen patients who require vaccinations 

# data[].attributes.headline
 Coordinate multi-disciplinary team discussion

# data[].attributes.subject
 Coordinate multi-disciplinary team discussion

# data[].attributes.headline
Review lab results and separate normal from abnormal 

# data[].attributes.subject
Review lab results and separate normal from abnormal 

# data[].attributes.headline
 Identify patients without medical visit in last 6 months and do outreach to bring patient into clinic

# data[].attributes.subject
 Identify patients without medical visit in last 6 months and do outreach to bring patient into clinic

# data[].attributes.headline
Complete medication reconciliation for patients

# data[].attributes.subject
Complete medication reconciliation for patients

# data[].attributes.headline
 E-order mammograms and provide basic health education

# data[].attributes.subject
 E-order mammograms and provide basic health education

# data[].attributes.headline
 Follow-up with patient with stable hypothyroidism

# data[].attributes.subject
 Follow-up with patient with stable hypothyroidism

# data[].attributes.headline
Identify patients overdue for HbA1c and e-order it

# data[].attributes.subject
Identify patients overdue for HbA1c and e-order it

# data[].attributes.headline
Follow up with patients for community resource referrals (e.g. community nurse post) and ensure that patient/caregiver received the care.

# data[].attributes.subject
Follow up with patients for community resource referrals (e.g. community nurse post) and ensure that patient/caregiver received the care.

# data[].attributes.headline
Review ACE/ARB panel results for patient who was newly started on ACE/ARB

# data[].attributes.subject
Review ACE/ARB panel results for patient who was newly started on ACE/ARB

# data[].attributes.headline
Monitor the empanelled patients and identify the high needs patients proactively

# data[].attributes.subject
Monitor the empanelled patients and identify the high needs patients proactively

# data[].attributes.headline
Treat uncomplicated urinary tract infections

# data[].attributes.subject
Treat uncomplicated urinary tract infections

# data[].attributes.headline
Track Emergency Department (ED) referrals to ensure completion

# data[].attributes.subject
Track Emergency Department (ED) referrals to ensure completion

# data[].attributes.headline
Review same day appointment availability for various healthcare providers before the start of the clinic session

# data[].attributes.subject
Review same day appointment availability for various healthcare providers before the start of the clinic session

# data[].attributes.headline
Screen older patients for frailty and falls

# data[].attributes.subject
Screen older patients for frailty and falls

# data[].attributes.headline
Assist patient with asthma/COPD to complete ACT/CAT form

# data[].attributes.subject
Assist patient with asthma/COPD to complete ACT/CAT form

# data[].attributes.headline
Inform patients of community resources and make referrals

# data[].attributes.subject
Inform patients of community resources and make referrals

# data[].attributes.headline
Communicate with hospital inpatient team regarding patient post discharge plans

# data[].attributes.subject
Communicate with hospital inpatient team regarding patient post discharge plans

# data[].attributes.headline
Check patient’s blood pressure and weight before consult 

# data[].attributes.subject
Check patient’s blood pressure and weight before consult 