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Implementation Guide – Combined Module 1 & Module 2

Ready, Set, Go! Getting (Re)Started with TAKEheart

Module Purpose This module combines the concepts introduced separately in Module 1 and 2. We introduce AHRQ’s TAKEheart initiative, whose goal is to help hospitals and health systems implement evidence-based strategies to increase cardiac rehabilitation (CR) participation among eligible patients by implementing automatic referral with care coordination support. We provide information hospitals and health systems can use to make the case for the project to their teams and leadership. Then, we move into the concrete activities hospitals need to undertake to get started in TAKEheart.

Target Audience Primary audience: CR Team implementing automatic referral with care coordination.

Secondary audiences: Non-team cardiac clinicians, discharge planners, care coordinators, hospital leaders

Learning Objectives* Upon completion of this module, you should be able to:

• Understand TAKEheart and the opportunity it provides to close the gap between evidence and practice to increase patient participation in cardiac rehabilitation.

• Make the case to your leadership for taking active steps to increase CR participation by implementing automatic referral and care coordination support and begin to build buy-in among other members of your implementation team.

• Understand the role of CR champion in the quality improvement project. • Identify key members of a multidisciplinary CR QI team, e.g., representatives from key

departments and patient advisors. • Create an aim statement as part of an overall action plan for implementation of automatic

referral with effective care coordination.

Key Takeaways from the Module

• There is ample evidence that CR is beneficial for patients, hospitals/health systems and payers o CR reduces mortality over 1-3 years after a cardiac event. o CR reduces re- hospitalization and adverse events, such as subsequent MI.

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o CR can help patients with medication adherence, and management of multiple chronic conditions, diabetes, depression, mental stress and improves quality of life after an adverse event.

• Despite these demonstrated benefits, less than one quarter of eligible patients participate in CR.

• Two evidence-based strategies—automatic referral and care coordination- effectively increase cardiac rehabilitation participation but they have not been widely implemented.

o Automatic referral with care coordination support increased participation to 86% • Insurers are showing interest in referral rates as measures of quality and factors to consider in

value-based payment. For example, closed referral loop measures track the percentage of patients referred for CR who enroll within a specified timeframe. These measures emphasize the importance of referral and adherence in CR.

• TAKEheart is providing training and technical assistance to help Partner Hospitals implement automatic referral with care coordination support; the action steps described in this combined training module will help you lay the foundation for future implementation activities.

• The aim statement guides the action plan and provides the project focus for the team. Tasks associated with the action plan are iterative and evolve over the life of the project.

Action Steps: Putting Knowledge into Practice STEP 1: Make the case for TAKEheart to your leadership and cardiac rehabilitation team.

• Review Module 1 materials, especially the one-page TAKEheart Benefits Fact Sheet (Appendix A) to ensure understanding and identify some key points you can cite in “elevator speeches” tailored to your most important audiences about the importance of CR and, for Partner Hospitals, why your team is committed to implementing it.

• Know your audiences -- people or groups who can affect your implementation efforts -- and prepare to tailor your message to them. Be sure to identify differences in the priorities and concerns of key leaders in different functional areas -- clinical, operational, quality and safety, IT, and financial. Note important differences between the concerns and priorities of departmental, service line and mid-management, and senior executives. The “pitches” you make should be customized to the audience.

• Make a table or list showing the main people or groups in your system whose cooperation you will need.

o Specify the benefits of CR that are most likely to appeal to each audience. o Select information from Module 1 that highlights benefits that will appeal to each

audience. o Identify any concerns or sources of opposition that influential people or groups may

have. o Think of ways to reduce or avoid these sources of resistance.

For example:

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Audience CR Benefits Evidence of Benefits

Potential Barrier/Opposition

Ways to Reduce Barrier/Opposition

Clinical manager

-Improving patient health

-Reducing adverse events

- CR reduces morbidity and mortality and improves quality of life

-CR reduces avoidable re-hospitalizations

Knowing/ making time to decide which patients to refer to CR

Implementing an automatic referral (specifics of HOW to do this will be covered as part of the TAKEheart Learning Community) allows patients to be automatically identified based on their characteristics and their care management can be subsequently tracked electronically

Finance team/billing manager

-Revenue optimization

-Clear billing procedures

- CR participation, reporting of quality metrics can drive value-based payment

- CR covered by Medicare Part B and most private insurance; CPT codes: 93798, 93797

Cost of implementation

CR has been shown to reduce readmission rates; improved health outcomes are increasingly rewarded by insurers

• Learn to make the case; find colleagues on whom to try out your elevator speeches. • Identify opportunities to make the case by arranging to talk with colleagues in each of your

key audiences.

STEP 2: Understand the role of the CR Champion.

The CR champion is vital for the implementation process.

• The CR champion needs to be a credible, influential, and trusted member of the cardiac care group at the hospital.

• The champion and formal team leader might be different people. e.g., the champion might be a cardiologist capable of working with his/her peers and explaining the importance of the effort to top management but not available to make sure the whole change process moves forward.

• Requires skills to engage and collaborate with hospital leadership to build buy-in and help marshal resources to set the course for automatic referral with care coordination.

• Persuades key stakeholders and disseminates the message about the value of both cardiac rehab and automatic referral with care coordination.

• Helps build a culture to support the changes being implemented for automatic referral with care coordination.

• Manages conflicting interests and scarce resources to move the project forward.

STEP 3: Create a Multidisciplinary Cardiac Rehabilitation Implementation Team.

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Form a multidisciplinary team to serve as the foundation for system change. • Decide who will be involved with implementing automatic referral and establishing effective

care coordination. • Start with a few key members for the multidisciplinary team, then as you build momentum

you can add team members. • Select action-oriented individuals who have credibility with peers and possess good

communication skills. • Include individuals involved in all parts of the cardiac rehabilitation workflow process. Crucial

members are likely to include: o IT representatives with the expertise needed to set up an automatic or “opt-out”

electronic referral of all eligible patients to CR. o Physicians: internal medicine, cardiology, surgeons, and interventionalists, physician

assistants, nurses and other allied health professionals who can advocate for automatic referral with peers and other clinicians.

o Hospital QI staff and managers who can bring expertise in leading organizational change.

o Patients (including CR graduates) who, as end users, can bring valuable insights about the process. If the hospital has patient family advisory committee, consider asking them to participate.

o Other CR staff (if applicable) • Plan for coordination across inpatient and outpatient settings by involving staff members

from both. • Set up designated meeting time for the team. • Develop meeting agendas and materials. • Set up daily/weekly/monthly huddles and check-ins with different members of the team for

status updates on the action plan tasks, sharing information and data about the project, celebrating successes, and generating new ideas.

• Establish data and monitoring plan. • Determine what is needed in terms of infrastructure, cost, and technical expertise to

implement automatic referral with care coordination.

STEP 4: Create an Action Plan.

Element 1: Develop an aim statement.

• Hold a meeting to create an aim statement for the project-- a summary of what the team hopes to achieve with TAKEheart. Use the following link to help guide the process: http://www.ihi.org/resources/Pages/Tools/Aim-Statement-Worksheet.aspx

• The aim statement answers the question: What are you trying to accomplish? • The aim statement is an explicit statement about the desired outcome of the project and

serves as the compass for the project. • Write a S.M.A.R.T. goal for the project as part of the aim statement.

o Specific: describe a specific outcome or process. o Measurable: define criteria for project success. o Achievable: set the bar for project success. o Relevant: must pertain to the aim of the project. o Timebound: must have start and finish dates.

• Include all team members.

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o Needs to reflect the team’s shared vision. o Every member should be involved to ensure buy-in. o A goal cannot be dictated, consensus must be reached so every member can get

behind the mission and vision of project.

Element 2: Determine how to assess or measure progress.

• Data is vital for understanding if the changes are working and progress is being made. • Assess data in the short-term as well as the long-term to understand if change is being

sustained over time. • Data tracking promotes quality improvement, specifically improving CR referral and

participation rates. • Data can illuminate any gaps and areas to concentrate on to improve those outcomes. • Better collection and tracking of data may also support reporting of performance and quality

metrics (more, better data can increase reliability of measures reported) and can improve those rates (better quality data increases ability to report complete measures; and improved processes can lead to better outcomes).

• Set S.M.A.R.T goals for measures.

Element 3: Tasks, Responsibilities & Responsibilities

• Use the Action Plan Template (Appendix B) to begin operationalizing the project by listing tasks and subtasks that will need to be completed.

• Assign a specific person to lead or complete each task. Unassigned tasks do not get completed!

• Set a target dates for completion of the individual tasks. Some tasks might be very quick to accomplish others might take some time.

• Remember, the action plan is an iterative document. Tasks will evolve over time as you learn more about implementing an automatic referral system and enhancing care coordination. Some will be accomplished while others are added. However, tasks are always guided by the project aim statement.

• 17 tasks have been included in the drop-down for the task column, but you can also add your own.

o These 17 tasks were included to get you thinking, they are high level tasks successful hospitals took to improve their patients’ access to, and participation in CR. The template includes an example highlighted in RED.

o These tasks were culled from the Million Hearts/AACVPR Cardiac Rehabilitation Change Package (CRCP) and recommended by national CR experts who have successfully implemented automatic referral with care coordination in their own hospitals.

o They were identified as critically important to success and achieving them will help you make progress in implementing automatic referral with care coordination.

o Certain tasks might be achieved before starting the intervention, others may not be relevant.

o The prepopulated tasks might help define additional tasks required to successfully implement automatic referral with care coordination.

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• Five of the high-level tasks have been deemed especially important by CRCP authors, change management specialists and others experienced in implementing automatic referral and care coordination.

• These are the five tasks that the TAKEheart Project Team will track for each hospital as part of the evaluation of the TAKEheart initiative.

o Develop EMR specifications for the automatic referral. o Implement the tested automatic referral system. o Design an effective care coordination system for CR with written roles or job

descriptions. o Develop training materials for the care coordination system. o Implement a care coordination system for CR.

• Establish S.M.A.R.T. goals for each task. • Consider resource needs and priorities.

o Additional features might need to be added to the EHR system. o Data labor hours for data management and analysis o Additional headcount

Key Resources:

Appendix A: TAKEheart Benefits Fact Sheet

Appendix B: Action Plan Template

Appendix C: Module Resources

*This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical education through the joint providership of the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) and the American Hospital Association (AHA). ABQAURP is accredited by the ACCME to provide continuing medical education for physicians.

The American Board of Quality Assurance and Utilization Review Physicians, Inc. designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABQAURP is an approved provider of continuing education for nurses. This activity is designated for 1.0 contact hours through the Florida Board of Nursing, Provider # 50-94.

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Appendix A: TAKEheart Benefits Fact Sheet

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Appendix B: Action Plan Template

Instructions: The template below is designed to assist you with the creation of your hospital’s TAKEheart Action Plan. Please work with your hospital team to develop tangible steps towards implementing automatic referral and enhancing care coordination.

The Task column allows you to choose a prepopulated task or enter a task your organization has determined it needs to undertake to successfully implement automatic referral (AR) and effective care coordination (CC). The prepopulated tasks are those that have been identified in the Million Hearts/AACVPR Cardiac Rehabilitation Change Package (CRCP) as important for successful implementation of AR and CC. Specific guidance on accomplishing these tasks is covered throughout the TAKEheart training curriculum.

In the Task Lead column, type in the name of the person responsible for the task. The S.M.A.R.T Goal column allows for free text typing. The Status column allows you to track task progress by clicking on a prepopulated option or typing your own. A calendar drop down will appear when you click on the Finish Date column. This column indicates the actual date the task was accomplished. The Comment column provides a free text box to add notes about the task.

The template provides an initial table with two rows. The first row shows an example for each column. Additional rows can be added by clicking on the last row of the table. A blue (+) sign will appear on the right side, click on the (+), an additional row will be added. You can add as many rows as you need.

Once you complete your action plan, share the document with us. The information you share with us will not be provided to AHRQ or other TAKEheart participants in any identifiable way; however, it will help us to ensure that the trainings and Partner Hospital Peer Action Groups (PH-PAGs) directly address the needs reflected in your action plan document. If you complete this document electronically on your computer, you can email it to us at: TAKEheart@abtassoc.com. If you prefer to complete a hard copy of this document, that is great too. You can scan the document and email it to us or just take a picture of each page on your phone and send us the pictures by email.

If you have any questions about completing this action plan activity, please reach out to us at the email address above.

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ACTION PLAN

Hospital Name:

Team Members, Role:

Aim Statement:

(Example: We aim to increase the number of patients with MI, PCI and CABG who are referred, enrolled, and participatein cardiac rehabilitation by 30%. This is important because we want to improve patient care and outcomes and reduce hospital readmissions. We will accomplish this aim by implementing automatic referral with care coordination by March 31,2022. We intend to see a 30% increase in current participation rates by December 31, 2022.)

Task Task Lead S.M.A.R.T. Goal(Specific,

Measurable,Achievable,Relevant,

Timebound)

Status Finish Date

Comments (challenges/facilitators)

Develop specifications for the automatic referral in the EMR system.

Luna Patel Beginning 6/4/2021, the CR QI team will

meet with IT representatives each

Tuesday and Thursday at noon for a half hour to define

the changes necessary for automatic referral and will complete the

task by 7/28/2021.

Completed 8/13/2021 Took longer because IT staff had limited ability to attend

meetings

Choose a task or enter your own.

Enter name.

Click here to enter a goal.

Choose or add one.

Click to enter a date.

Click to enter comments.

Choose a task or enter your own.

Enter name.

Click here to enter a goal.

Choose or add one.

Click to enter a date.

Click to enter comments.

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Appendix C: Module Resources

*Note: IHI resources require free registration to login.

Materials cited in this Implementation Guide and in the Module 1 & 2 webinar slide deck include:

1. Institute for Healthcare Improvement (IHI). “Quality Improvement Essentials Toolkit.” 2020. Available at:http://www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx

IHI’s QI Essentials Toolkit includes the tools and templates to launch a successful quality improvement projectand manage performance improvement. These tools include a short description, instructions, an example, and ablank template.

2. Institute for Healthcare Improvement (IHI). “Aim Statement Worksheet.” 2020. Available at:http://www.ihi.org/resources/Pages/Tools/Aim-Statement-Worksheet.aspx

IHI’s Aim Statement Worksheet provides guidance around writing an effective aim statement, which delineatesclear and specific plans for upcoming improvement work.

3. Institute for Healthcare Improvement (IHI). “Project Planning Form.” 2020. Available at:http://www.ihi.org/resources/Pages/Tools/ProjectPlanningForm.aspx

The Project Planning Form is a useful tool to help teams think systematically about their improvement project,including a listing of the changes that the team is testing, the person responsible for each test of change, and thetimeframe for each test. The form allows a team to see at a glance the overall of the project.

4. McNeil, Patrick. “Clinical Champions.” Liverpool Hospital. Available at:https://www.health.nsw.gov.au/wohp/Documents/mc3-clinical-champions-mcneil.pdf

This PowerPoint, created by Liverpool Hospital, suggests the roles, responsibilities, and recruitment of clinicalchampions.

5. Centers for Disease Control and Prevention. “Million Hearts: Getting to 70% Cardiac Rehabilitation Participation:Action Steps for Hospitals.” Available at:https://www.aacvpr.org/Portals/0/Million%20Hearts%20Change%20Package/4.24.2018%20Files/SC-3-CRCP-MH-Actions%20for%20Hospitals.pptx

This PowerPoint, created by CDC’s Million Hearts, outlines both clinical and community-based steps for hospitalsto optimize their cardiac rehabilitation programs.

6. Centers for Disease Control and Prevention. “Million Hearts: Tools and Protocols.” Available at:https://millionhearts.hhs.gov/tools-protocols/index.html

This webpage, developed by the CDC’s Million Hearts, provides tools, protocols, and action guides to improvepatients’ cardiovascular health.

7. Centers for Disease Control and Prevention: Million Hearts. Cardiac Rehabilitation: Saving Lives, RestoringHealth, Preventing Disease.” 2018. Available at: https://millionhearts.hhs.gov/files/Cardiac_Rehab_Infographic-508.pdf

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The CDC’s Million Hearts “Saving Lives, Restoring Health, Preventing Disease” infographic provides an overview of the individual and systemic benefits of cardiac rehabilitation, the common barriers to referral and enrollment, and some potential interventions for reducing this gap.

8. Health Information Technology, Evaluation, and Quality Center. “Guide to Improving Care Processes andOutcomes in Health Centers: An Approach to Quality Improvement.” 2016. Available at:https://hiteqcenter.org/Resources/HITEQ-Resources/guide-to-improving-care-processes-and-outcomes-in-health-centers

This quality improvement approach can be used to augment current QI approaches used in your health center orcan serve as a placeholder QI methodology when there isn’t already a robust QI process in place.

9. TMIT Consulting, LLC. “Clinical Decision Support Quality Improvement Worksheet.” 2016. Available at:http://hiteqcenter.org/Portals/0/pdf/HITEQ%20HIT%20QI%20Guide%20CDS%20QI%20Worksheet_Essential.docx

This tool can help users document and analyze current approaches to specific quality improvement targets andplan enhancements.

10. Centers for Disease Control and Prevention. U.S. Department of Health and Human Services. CardiacRehabilitation Change Package. 2018. Available at: https://millionhearts.hhs.gov/tools-protocols/action-guides/cardiac-change-package/index.html

The Cardiac Rehabilitation Change Package includes change concepts, change ideas, tools and resources to helphospitals put strategies in place to improve cardiac care for their eligible patients.

11. Centers for Disease Control and Prevention: Million Hearts. Cardiac Rehabilitation: Saving Lives, RestoringHealth, Preventing Disease” 2018. Available at: https://millionhearts.hhs.gov/files/Cardiac_Rehab_Infographic-508.pdf

The CDC’s Million Hearts “Saving Lives, Restoring Health, Preventing Disease” infographic provides an overview of the individual and systemic benefits of cardiac rehabilitation, the common barriers to referral and enrollment, and some potential interventions for reducing this gap.

12. American Association of Cardiovascular and Pulmonary Rehabilitation. Vital Conversations with Medical Teams& Hospital Administrators About Cardiac Rehabilitation Services Delivering Value Based Care. 2018. Available at:https://www.aacvpr.org/Portals/0/Million Hearts Change Package/4.24.2018 Files/SC-2-5-CRCP-CrucialConversations with Med Providers and Hosp Admins.pptx

This PowerPoint presentation suggests approaches for presenting the benefits of cardiac rehabilitation to serviceline medical teams and hospital administration to promote system changes; and discusses referral, enrollment,and adherence strategies to improve the value proposition of CR services.

13. P.A. Ades, S.J. Keteyian, J.S. Wright, et al. Increasing cardiac rehabilitation participation from 20% to 70%: a roadmap from the million hearts cardiac rehabilitation collaborative. Mayo Clin Proc, 92 (2) (2017), pp. 234-242.Available at: http://dx.doi.org/10.1016/j.mayocp.2016.10.014

This article highlights two interventions — electronic medical record-based prompts and care coordination —that can increase enrollment in and adherence to cardiac rehabilitation.

14. Ritchey MD, Maresh S, McNeely J, Shaffer T, Jackson SL, Keteyian SJ, Brawner CA, Whooley MA, Chang T, StolpH, Schieb L, Wright J. Tracking Cardiac Rehabilitation Participation and Completion Among Medicare

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Beneficiaries to Inform the Efforts of a National Initiative. Circ Cardiovasc Qual Outcomes. 2020 Jan;13(1):e005902. doi: 10.1161/CIRCOUTCOMES.119.005902. Epub 2020 Jan 14. PMID: 31931615; PMCID: PMC8091573.

This article highlights the benefits of tracking cardiac rehabilitation participation and completion.

15. S L. Grace, K L. Russell, R D Reid, et al Effect of Cardiac Rehabilitation Referral Strategies on Utilization Rates: A Prospective, Controlled Study. Arch Intern Med. 2011; 171(3):235-241. Available at: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/416448 This article presents findings that automatic referral combined with a liaison is more effective at increasing CR referral rates as compared with either intervention on its own.

16. R J. Thomas, G Balady, G Banka, et al. 2018 ACC/AHA Clinical Performance and Quality Measures for Cardiac

Rehabilitation. J Am Coll Cardiol. 2018 Apr, 71 (16) 1814-1837. Available at: http://www.onlinejacc.org/content/71/16/1814#targetText=The%20American%20College%20of%20Cardiology%20(ACC)%2FAmerican%20Heart%20Association,scientific%20evidence%20into%20clinical%20practice.&targetText=The%20ACC%2FAHA%20Task%20Force,quality%20measures%20from%20performance%20measures

This report by the American College of Cardiology summarizes performance and quality measures for cardiac rehabilitation. Its goal is to provide practitioners and institutions with tools to measure quality of care and identify opportunities for improvement.