Change Packages and Interventions

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Influenza Immunization Change Package for Health Care Teams
Health care professionals from all care settings are encouraged to use the resources listed in this TMF Quality Innovation Network change package to help care for patients diagnosed with the flu. Note, you must log into this website to download this change package.
Adobe PDF    Date Added: 06/28/2022    Date Last Modified: Jun 28 2022 2:06PM  
2018 ACC/AHA Clinical Performance and Quality Measures for Cardiac Rehabilitation
This report from the American College of Cardiology (ACC) and the American Heart Association (AHA) describes how the Task Force on Performance Measures (Task Force) revised the clinical performance and quality measures for cardiac rehabilitation (CR). The Task Force created a comprehensive list of measures that can be used for patients who are eligible to participate in CR. The list includes six new performance measures and three new quality measures.
Adobe PDF    Date Added: 05/06/2022    Date Last Modified: May 6 2022 9:02AM  
Cardiac Rehabilitation and Implications During the COVID-19 Era
The COVID-19 pandemic disrupted the traditional, facility-based cardiac rehabilitation model (CR). This expert analysis from the American College of Cardiology, however, finds that home-based cardiac rehabilitation is an effective alternative to traditional CR. The analysis further notes that, as the pandemic continues, using a home-based rehabilitation CR program can help protect patients while achieving cardiovascular outcomes.
Web link    Date Added: 05/06/2022    Date Last Modified: May 6 2022 8:59AM  
How to Improve
The Institure for Healthcare Improvement uses the Model for Improvement as the framework to guide improvement work. This website explains the change process.
Web link    Date Added: 05/06/2022    Date Last Modified: May 6 2022 9:29AM  
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) Intervention List
Download this two-page handout the TMF Quality Innovation Network created to help health care providers and practitioners find and implement quality improvement interventions to help patients take an active role in managing their diabetes and prediabetes.
Adobe PDF    Date Added: 05/05/2022    Date Last Modified: May 5 2022 10:35AM  
Optimize your EHR to prevent type 2 diabetes
The American Medical Association offers suggestions and guidance on how providers can use electronic health records (EHRs) and technology to improve care for patients with prediabetes.
Adobe PDF    Date Added: 05/05/2022    Date Last Modified: May 5 2022 12:33PM  
Guide to Clinical Care and Patients with Diabetes and Established Cardiovascular Risk
In the Know Diabetes by Heart Pocket Guide, the American Heart Association and the ADA summarize key clinical recommendations for cardio-metabolic health management for people with type 2 diabetes.
Adobe PDF    Date Added: 05/05/2022    Date Last Modified: May 5 2022 12:36PM  
ADCES7 Self-Care Behaviors™ REDUCING RISKS
Providers can give this handout to patients diagnosed with prediabetes or type 2 diabetes. This patient education tool from the Association of Diabetes Care & Education Specialists (ADCES7) is intended to help patients take an active role in keeping their hearts, kidneys and eyes healthy while they manage their diabetes.
Adobe PDF    Date Added: 05/05/2022    Date Last Modified: May 5 2022 12:44PM  
Diabetes INSIDE: Improving Population HbA1c Testing and Targets in Primary Care with a Quality Initiative
Read how Tulane Medical Group used the Diabetes INSIDE (Inspiring System Improvement with Data-Driven Excellence) program to conduct a multiyear review of outpatient EHRs to improve outcomes of patients with adult type 2 diabetes. The goal: to decrease hemoglobin A1C (HbA1c) under-testing, reduce the number of patients with poor glycemic control and lower HbA1c levels.
Web link    Date Added: 05/05/2022    Date Last Modified: May 5 2022 12:38PM  
Information for Health Care Professionals
The National Diabetes Prevention Program—or National DPP—was created in 2010 to address the increasing number of people diagnosed with prediabetes and type 2 diabetes in the United States. Health care professionals can refer their at-risk patients to a CDC-recognized lifestyle change program that focuses on changing certain habits and behaviors that contribute to poor health.
Web link    Date Added: 05/05/2022    Date Last Modified: May 5 2022 12:41PM  
Tobacco Cessation Change Package
This quality improvement tool, created by the CDC, is intended for health care professionals in outpatient, inpatient and behavioral health settings that work with public health professionals who provide treatment to patients who use tobacco. The change package can help clinical teams increase the reach and effectiveness of tobacco cessation interventions and incorporate these interventions into the clinical workflow.
Web link    Date Added: 05/04/2022    Date Last Modified: May 4 2022 8:22AM  
Tobacco Cessation Change Package, PDF
This quality improvement tool, created by the CDC, is intended for health care professionals in outpatient, inpatient and behavioral health settings that work with public health professionals who provide treatment to patients who use tobacco. The change package can help clinical teams increase the reach and effectiveness of tobacco cessation interventions and incorporate these interventions into the clinical workflow.
Adobe PDF    Date Added: 05/04/2022    Date Last Modified: May 4 2022 8:23AM  
The North American Quitline Consortium (NAQC)
NAQC is an international, non-profit membership organization that promotes evidence-based quitline services across diverse communities in North America. More than 400 organizations and individuals make up NAQC’s membership. NACQ members help fund quitlines, conduct research around quitline-related topics, advance national cessation policies, and work in other areas of tobacco control. NAQC’s Quitline Map shows contact information and services offered in the United States and Canada.
Web link    Date Added: 05/04/2022    Date Last Modified: May 4 2022 8:26AM  
The North American Quitline Consortium (NAQC), Map
NAQC’s Quitline Map shows contact information and services offered in the United States and Canada.
Web link    Date Added: 05/04/2022    Date Last Modified: May 4 2022 8:28AM  
Empanelment: Establishing Patient-Provider Relationships - Implementation Guide
The Safety Net Medical Home Initiative produced this comprehensive guide to help medical practices, providers and care teams make a shift from caring for individual patients to managing the health of a defined population of patients. The guide focuses on the provider panel manager’s role and responsibilities in fostering proactive preventive and chronic illness care.
Adobe PDF    Date Added: 04/29/2022    Date Last Modified: Apr 29 2022 1:14PM  
Risk Stratification: A Two-Step Process for Identifying Your Sickest Patients
Risk stratification categorizes patients based on their health status and other factors and helps practices manage their patients according to their assigned risk level. This online article, published in FPM—an AAFP journal—describes how one practice uses a structured, algorithmic approach to determine its patients' risk levels and drive better care team support for its patients.
Web link    Date Added: 04/29/2022    Date Last Modified: Apr 29 2022 1:25PM  
Million Hearts: Cardiac Rehabilitation Change Package (PDF)
Patients who get outpatient CR after a cardiac-related event or procedure can reduce the risk of death and decrease hospital readmissions, while also improving their quality of life. Despite the benefits, participation in CR remains low. Download this change package, completed by the Centers for Disease Control and Prevention (CDC), to find out how you and you colleagues can become CR change agents for your practice.
Adobe PDF    Date Added: 04/29/2022    Date Last Modified: Apr 29 2022 1:29PM  
Million Hearts: Hypertension Control Change Package Second Edition
Created by the Centers for Disease Control and Prevention (CDC), this update to its 2015 change package responds to new clinical guidelines and reflects advances in improving HTN control. Included in this change packagare are more self-measured blood pressure (SMBP)-focused content and tools to help providers identify patients who may have HTN.
Web link    Date Added: 04/29/2022    Date Last Modified: Apr 29 2022 3:13PM  
TAKEheart Initiative: Building and Implementing a Successful Automatic Cardiac Rehab Referral System
Medical practices, providers and care teams use many referral patterns to ensure patients get outpatient CR. The TAKEheart Automatic Referral Implementation Guide, Module 5 (PDF) focuses on how to create an automatic referral system so patients can transition from the inpatient environment to outpatient CR.
Web link    Date Added: 04/29/2022    Date Last Modified: Apr 29 2022 1:31PM  
TAKEheart Initiative: Building and Implementing a Successful Automatic Cardiac Rehab Referral System (PDF)
Medical practices, providers and care teams use many referral patterns to ensure patients get outpatient CR. The TAKEheart Automatic Referral Implementation Guide, Module 5 (PDF) focuses on how to create an automatic referral system so patients can transition from the inpatient environment to outpatient CR. This guide provides a referral workflow a care team can follow.
Adobe PDF    Date Added: 04/29/2022    Date Last Modified: Apr 29 2022 1:34PM  
Million Hearts: Hypertension Control Change Package Second Edition (PDF)
Created by the Centers for Disease Control and Prevention (CDC), this update to its 2015 change package responds to new clinical guidelines and reflects advances in improving HTN control. Download this change package for more self-measured blood pressure (SMBP)-focused content and tools to help providers identify patients who may have HTN.
Adobe PDF    Date Added: 04/29/2022    Date Last Modified: Apr 29 2022 3:01PM  
Target: BP, Patient-Measured BP
According to the American Heart Association, which created the Target: BP website, patients who engage in SMBP may also seek to improve their health in other ways. This site explains how SMBP works and offers guidance in launching an SMBP program.
Web link    Date Added: 04/29/2022    Date Last Modified: Apr 29 2022 3:05PM  
Million Hearts: Cardiac Rehabilitation Change Package
Patients who get outpatient CR after a cardiac-related event or procedure can reduce the risk of death and decrease hospital readmissions, while also improving their quality of life. Despite the benefits, participation in CR remains low. See this change package, completed by the Centers for Disease Control and Prevention (CDC), to find out how you and you colleagues can become CR change agents for your practice.
Web link    Date Added: 04/29/2022    Date Last Modified: Apr 29 2022 1:23PM  
Keys to High Quality, Low Cost Care: Empanelment, Attribution and Risk Stratification
Risk stratification categorizes patients based on their health status and other factors and helps practices manage their patients according to their assigned risk level. This online article, published in FPM—an AAFP journal—describes how one practice uses a structured, algorithmic approach to determine its patients' risk levels and drive better care team support for its patients.
Adobe PDF    Date Added: 04/29/2022    Date Last Modified: Apr 29 2022 1:25PM  
Million Hearts, Protocol for Controlling Hypertension in Adults (PDF)
The CDC created this workflow template that practices can modify to better work with patients to control their HTN.
Adobe PDF    Date Added: 04/29/2022    Date Last Modified: Apr 29 2022 3:08PM  
COVID-19 Vaccination Change Package for Health Care Teams
Health care professionals from all care settings are encouraged to use the resources listed in this TMF Quality Innovation Network change package to help care for patients diagnosed with COVID-19. Note, you must log into this website to download this change package.
Adobe PDF    Date Added: 03/11/2021    Date Last Modified: Mar 24 2022 10:56PM  
Improve Patient Safety and Prevent Adverse Drug Events in the Community Change Package
The TMF Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services, designed this change package to provide strategies to address adverse drug events in all community settings.
Adobe PDF    Date Added: 10/02/2020    Date Last Modified: Mar 24 2022 9:52AM  
Improve the Quality of Care Transitions Change Package
The TMF Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services, designed this change package to provide strategies to improve the quality of care transitions.
Adobe PDF    Date Added: 09/30/2020    Date Last Modified: Mar 24 2022 11:05AM  
Improving Chronic Disease Self-Management Chronic Kidney Disease Change Package
The TMF Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services, designed this change package to provide strategies to address and prevent the progression of chronic kidney disease to end-stage renal disease.
Adobe PDF    Date Added: 09/28/2020    Date Last Modified: Sep 28 2020 7:18PM  
Improving Chronic Disease Self-Management Diabetes Change Package
The TMF Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services, designed this change package to provide strategies to address diabetes prevention, self-management and care.
Adobe PDF    Date Added: 09/28/2020    Date Last Modified: Oct 1 2020 1:29PM  
Improving Chronic Disease Self-Management Cardiovascular Disease Change Package
The TMF Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services, designed this change package to provide strategies to address the prevention of cardiovascular disease events by improving blood pressure control and cholesterol management.
Adobe PDF    Date Added: 09/28/2020    Date Last Modified: Dec 18 2020 12:32PM  
Increase Patient Safety, Infection Prevention and Control in the Community Change Package
The TMF Quality Innovation Network developed this document to assist health care professionals to increase patient safety by reducing C. diff rates and improving antibiotic stewardship in health care facilities serving high-risk fee-for-service Medicare beneficiaries.
Adobe PDF    Date Added: 05/26/2020    Date Last Modified: Dec 18 2020 1:06PM  
Improving Behavioral Health Outcomes with a Focus on Decreasing Opioid Misuse Change Package
This TMF Quality Innovation Network change package provides a menu of options from which you can select specific interventions to develop an action plan that improves opioid-related outcomes and increases access to behavioral health services.
Adobe PDF    Date Added: 05/20/2020    Date Last Modified: Mar 24 2022 4:47PM  
Paquete para facilitar el cambio: Mejoremos los resultados de salud del comportamiento, enfocándonos en la reducción del uso inapropiado de opioides
TMF Quality Innovation Network, en virtud del contrato con CMS, preparó este paquete para facilitar el cambio y proporcionar a las comunidades estrategias para combatir el abuso, el uso inapropiado y las sobredosis de opioides y aumentar el acceso a los servicios de salud del comportamiento.
Adobe PDF    Date Added: 06/08/2021    Date Last Modified: Mar 24 2022 4:49PM  
Vacunación contra la pulmonía: Paquete para facilitar el cambio para los equipos de atención médica
Se recomienda a los profesionales médicos de todos los entornos de atención que usen los recursos enumerados en este Paquete para facilitar el cambio como ayuda para brindar atención a los pacientes diagnosticados con pulmonía.
Adobe PDF    Date Added: 06/08/2021    Date Last Modified: Jun 8 2021 5:12PM  
Vacunación contra el COVID-19: Paquete para facilitar el cambio para los equipos de atención médica
Se recomienda a los profesionales de atención médica que usen los recursos enumerados en este paquete para facilitar el cambio como ayuda para brindar atención a los pacientes diagnosticados con el COVID-19.
Adobe PDF    Date Added: 05/24/2021    Date Last Modified: May 24 2021 6:58PM  
Vacunación contra la influenza: Paquete para facilitar el cambio para los equipos de atención médica
Se recomienda a los profesionales de atención médica que usen los recursos enumerados en este paquete para facilitar el cambio como ayuda para brindar atención a los pacientes diagnosticados con influenza.
Adobe PDF    Date Added: 05/24/2021    Date Last Modified: May 24 2021 6:58PM  
Paquete para facilitar el cambio: Mejorar la seguridad del paciente y prevenir los eventos adversos relacionados con la administración de los medicamentos, para Puerto Rico
La Red de Innovación de la Calidad de TMF, bajo contrato con los Centros de Servicios de Medicare y Medicaid, diseñó este paquete de cambios para proporcionar las estrategias para abordar los eventos adversos de medicamentos.
Adobe PDF    Date Added: 04/13/2021    Date Last Modified: Mar 18 2022 8:15AM  
Paquete para facilitar el cambio: Mejoramiento de la seguridad del paciente y la prevención y el control de las infecciones en la comunidad, para Puerto Rico
TMF Quality Innovation Network diseñó este documento para ayudar a los profesionales de atención médica a aumentar la seguridad de los pacientes al reducir las tasas de infección con C. diff y mejorar el uso responsable de los antibióticos en las facilidades de atención médica que dan servicio a beneficiarios de pago por servicios de Medicare en alto riesgo.
Adobe PDF    Date Added: 11/30/2020    Date Last Modified: Nov 30 2020 4:44PM  
Paquete para facilitar el cambio: Mejoramiento del automanejo de enfermedades crónicas – Enfermedades cardiovasculares, para Puerto Rico
TMF Quality Innovation Network, según el contrato con los Centros de Servicios de Medicare y Medicaid, diseñó este paquete para facilitar el cambio a fin de proporcionar estrategias para abordar la prevención de eventos relacionados con las enfermedades cardiovasculares al mejorar el control de la presión arterial y del colesterol.
Adobe PDF    Date Added: 11/30/2020    Date Last Modified: Nov 30 2020 4:48PM  
Paquete para facilitar el cambio: Mejoramiento del automanejo de enfermedades crónicas – Insuficiencia renal, para Puerto Rico
TMF Quality Innovation Network, según el contrato con los Centros de Servicios de Medicare y Medicaid, diseñó este paquete para facilitar el cambio a fin de proporcionar estrategias para abordar y prevenir la progresión de la insuficiencia renal a insuficiencia renal terminal.
Adobe PDF    Date Added: 11/30/2020    Date Last Modified: Nov 30 2020 5:28PM  
Paquete para facilitar el cambio: Mejorar la calidad de las transiciones de atención, para Puerto Rico
TMF Quality Innovation Network, según el contrato con los Centros de Servicios de Medicare y Medicaid, diseñó este paquete para facilitar el cambio a fin de proporcionar estrategias para mejorar la calidad de las transiciones de atención.
Adobe PDF    Date Added: 11/30/2020    Date Last Modified: Mar 24 2022 11:06AM  
Paquete para facilitar el cambio: Mejoramiento del automanejo de enfermedades crónicas – Diabetes, para Puerto Rico
TMF Quality Innovation Network, según el contrato con los Centros de Servicios de Medicare y Medicaid, diseñó este paquete para facilitar el cambio a fin de proporcionar estrategias para abordar la prevención, el automanejo y la atención de la diabetes.
Adobe PDF    Date Added: 11/09/2020    Date Last Modified: Nov 11 2020 5:46PM