Toolkit for Outpatient Care of Severe, Chronic, Noncommunicable Diseases at First-Level Hospitals In many low- and lower-middle income countries, clinical services for chronic noncommunicable diseases (NCDs) are only available through urban referral centers. In rural areas, services for severe chronic NCDs such as type 1 diabetes and advanced rheumatic heart disease are unavailable even at district (first-level) hospitals. The PEN-Plus Toolkit contains seven sections, each of which has implementation tools in an editable format that can be adapted to local contexts: Implementation and Work Planning; Baseline Assessment; Clinical Guideline Development; Training and Mentorship; Progressive Decentralization; Medical Informatics and Monitoring and Evaluation