Change Packages and Interventions

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CHF 30-Day Readmission Huddle
This one-page tool can be used by providers and/or clinical staff members to record the details of each patient's hospitalization and discharge. The form will help health care workers collect information about the patient that can determine the focus of a post-discharge health care plan.
Adobe PDF    Date Added: 10/16/2024    Date Last Modified: Oct 16 2024 8:51AM  
The CEERIAS Study: Phase II
This report shares results of a continued study about how people in high-risk neighborhoods react to stroke. The study revealed barriers to care and identified promising tactics to overcome those barriers in predominantly Black and Hispanic Chicago neighborhoods.
Adobe PDF    Date Added: 10/07/2024    Date Last Modified: Sep 27 2024 12:52PM  
Examining At-Risk Stroke Communities During the COVID-19 Pandemic
This presentation discusses the unique challenges of at-risk acute stroke populations during COVID-19 and lessons learned from key strategies for developing meaningful patient and community partnerships.
Adobe PDF    Date Added: 10/07/2024    Date Last Modified: Sep 27 2024 12:56PM  
The CEERIAS Study: "Act FAST for Stroke."
In the Community Engagement in Early Recognition and Immediate Action in Stroke (CEERIAS) study, researchers sought to find a way for people in high-risk neighborhoods to react quickly to stroke. Researchers used the results to create an educational program that prepared community leaders and patient advocates to recognize and train others in the community on the need to “Act FAST for Stroke.”
Web link    Date Added: 10/06/2024    Date Last Modified: Sep 27 2024 12:33PM  
Cholesterol Management Change Package
This new resource from the Million Hearts initiative presents a listing of evidence-based process improvements that can be used to help patient with cholesterol management. The guide includes change concepts, change ideas and evidence- or practice-based tools and resources.
Adobe PDF    Date Added: 07/16/2024    Date Last Modified: Jul 12 2024 8:26AM  
Heart Failure Education and Rehab
The National Association of Chronic Disease Directors funded six organizations from across the U.S. to implement Million Hearts® strategies among priority populations to reduce health disparities and improve cardiovascular health.
Web link    Date Added: 07/07/2024    Date Last Modified: Jul 3 2024 12:58PM  
Symptom Tracker for Heart Failure Management
People with heart failure can use this tool to help them determine when they need to seek medical care for their condition.
Adobe PDF    Date Added: 05/22/2024    Date Last Modified: May 22 2024 12:37PM  
What to eat and how often
The Mediterranean Diet is the doctor-approved eating plan for all people. The diet suggests people eat more fresh fruits and vegetables and limit how much chicken and meat they eat. Health care providers can give this flyer to patients who should adopt an eating plan to help them manage chronic illnesses, such as heart disease and type 2 diabetes.
Adobe PDF    Date Added: 03/18/2024    Date Last Modified: Mar 18 2024 8:11AM  
Preventive Services to Improve Health Outcomes Series, Promoting Cardiac Health and Rehab Part 3
Watch this webinar recording featuring a provider education specialist from Novitas Solutions, a Medicare Administrative Contractor. This presentation shows how to bill for and manage payments for preventive services that promote cardiac health and cardiac rehabilitation.
WebEx    Date Added: 03/06/2024    Date Last Modified: Mar 8 2024 6:13AM  
Heart Failure Interactive Toolkit (Spanish for Puerto Rico)
This booklet is designed to give providers easy access to resources they can share with their patients who speak Spanish in a Puerto Rican dialect. The resources are intended to help patients better manage heart failure (HF), also known as congestive heart failure, (CHF).
Adobe PDF    Date Added: 11/27/2023    Date Last Modified: Nov 27 2023 2:38PM  
Hypertension: Handling the Pressure
In this episode of the Contagious Conversations podcast, physicians discuss the risks posed by hypertension, the steps we can all take to stay healthy and approaches to making hypertension control a national health priority.
Podcast    Date Added: 11/10/2023    Date Last Modified: Nov 29 2023 8:30AM  
Heart Failure Interactive Toolkit
This booklet is designed to give providers easy access to resources they can share to help patients better manage heart failure (HF), also known as congestive heart failure, (CHF).
Adobe PDF    Date Added: 08/23/2023    Date Last Modified: Aug 31 2023 1:11PM  
Quality Improvement for Heart Failure and Cardiac Rehabilitation
In this recorded, one-hour webinar, Jessica Wauson, from the American Heart Association, shares evidence-based guidelines for treating heart failure. Also featured: a review of the patient assessments and education tools that patients can use to successfully manage their condition.
Video    Date Added: 08/07/2023    Date Last Modified: Aug 7 2023 2:05PM  
Using AHRQ’s EvidenceNOW Model To Reduce Heart Disease Risk Could Have Meaningful Health Benefits
Read about the findings of a two-year study funded by the Agency for Healthcare Research and Quality (AHRQ). Released in May 2023, the study found, among other things, that using practices from AHRQ’s EvidenceNOW initiative could prevent more than 3,100 atherosclerotic cardiovascular disease (ASCVD) events over 10 years.
Web link    Date Added: 06/30/2023    Date Last Modified: Jun 30 2023 11:55AM  
International Consensus on Standardized Clinic Blood Pressure Measurement − A Call to Action
Accurate measurement is essential for effective blood pressure (BP) management. Emphasizing standardized BP measurements in clinical settings is a main focus in this joint statement from 13 scientific health organizations. Also included: a step-by-step process providers can follow to get accurate BP measurements.
Web link    Date Added: 05/23/2023    Date Last Modified: May 23 2023 9:30AM  
Health Disparities in Heart Failure Admissions Cost Over $60M
This article examines results of a study published in Health Affairs. One finding, according to researchers: health inequity costs the Medicare program more than $60 million on preventable heart failure hospital admissions.
Web link    Date Added: 05/23/2023    Date Last Modified: May 23 2023 9:33AM  
How does stress from everyday life impact heart health?
Stress has been linked to heart health complications, such as atrial fibrillation, coronary heart disease and sudden cardiac death. This article shares news from a team of UC Davis Health scientists who will study the impact of stress from everyday life on heart health in underserved communities.
Web link    Date Added: 05/23/2023    Date Last Modified: May 23 2023 9:43AM  
Million Hearts, Cardiac Rehabilitation Collaborative (CRC)
Learn more about the Million Hearts® Cardiac Rehabilitation Collaborative (CRC), which meets virtually each quarter. CRC members include cardiac rehabilitation (CR) professionals, clinicians and health care teams, and CR participants and their family members, among others. The goal: to increase CR referral, enrollment and adherence.
Web link    Date Added: 05/15/2023    Date Last Modified: May 15 2023 1:09PM  
Measuring And Addressing Nutrition Security To Achieve Health And Health Equity
This article explores food insecurity and the impact nutrition-related diseases have on health inequity and health care costs in the US and globally. The article also offers potential interventions to address nutrition security in different populations.
Web link    Date Added: 04/07/2023    Date Last Modified: Apr 7 2023 12:48PM  
Food Security: Key Dimensions of the Social Determinant of Health
This article examines how food access and security affects health and well-being. It states that many illnesses, such as heart disease and diabetes, may be diet-related. However, through community health partnerships, health care organizations are trying to connect patients in need with nutritious food.
Web link    Date Added: 04/07/2023    Date Last Modified: Apr 7 2023 12:18PM  
Physician Order Form for Cardiac Rehab
Providers can use this form when they want to refer patients to cardiac rehabilitation.
Adobe PDF    Date Added: 03/29/2023    Date Last Modified: Mar 29 2023 2:03PM  
Large-Scale Program to Reduce Heart Disease Risk Could Have Meaningful Health Benefits
A new study, funded by the Agency for Healthcare Research and Quality (AHRQ), suggests that widespread use of a large-scale intervention to support primary care practices in heart disease prevention could have life-saving benefits. The study, published in the Journal of the American Board of Family Medicine, found that the intervention could prevent more than 3,100 atherosclerotic cardiovascular disease events over 10 years and avoid $150 million in 90-day direct medical costs.
Web link    Date Added: 03/29/2023    Date Last Modified: Mar 29 2023 12:19PM  
Heart Failure Toolkit
This fact sheet from the TMF Quality Innovation Network can help patients better manage heart failure (HF), also known as congestive heart failure (CHF).
Adobe PDF    Date Added: 03/10/2023    Date Last Modified: Aug 31 2023 1:09PM  
Rural-Urban Health Disparities Persist with Higher Risk of Heart Failure
New National Institutes of Health data documents rural-urban health disparities, with this latest study finding that those living in rural regions are 19% more likely to develop heart failure than those living in urban areas. The study, published in JAMA Cardiology, also found that Black men living in rural areas were 34% more likely to develop heart failure than Black men in urban areas.
Web link    Date Added: 03/08/2023    Date Last Modified: Mar 8 2023 8:31AM  
Connecting Peripheral Artery Disease, Social Determinants of Health Could Lead to Earlier Diagnoses
This article addresses how social determinants of health (SDOH), such as food and housing insecurity can directly increase the burden of other blood vessel diseases, such as heart disease and stroke. Exploring and understanding the relationship between peripheral artery disease (PAD) and negative social determinants of health (SDOH) in older Black adults could lead to earlier diagnoses.
Web link    Date Added: 03/08/2023    Date Last Modified: Aug 22 2023 11:06PM  
How to Reduce Congestive Heart Failure Readmissions
In this video, Kimberly Jungkind, a health care quality improvement specialist with the TMF Quality Innovation Network-Quality Improvement Organization, discusses how to reduce readmissions for patients with congestive heart failure (CHF). Jungkind shares resources that support patients with CHF to better manage their condition, and she offers innovative ideas for helping patients with CHF buy and cook foods that are heart healthy.
Video    Date Added: 02/16/2023    Date Last Modified: May 29 2024 1:58PM  
Smoking and Cardiovascular Disease
Smoking increases the formation of plaque in blood vessels. Coronary Heart Disease occurs when arteries that carry blood to the heart muscle are narrowed by plaque or blocked by clots. Chemicals in cigarette smoke cause the blood to thicken and form clots inside veins and arteries.
Adobe PDF    Date Added: 02/13/2023    Date Last Modified: Feb 13 2023 6:17AM  
Cardiac Rehabilitation Medicine Tracker
This tool can help cardiac rehabilitation patients keep track of their medications.
Adobe PDF    Date Added: 01/11/2023    Date Last Modified: Jan 11 2023 7:45AM  
Medical Contact List
This tool gives patients a place to note their emergency contact numbers. Encourage patients to post the contact list in a place at home where other family members can see it.
Adobe PDF    Date Added: 01/11/2023    Date Last Modified: Jan 11 2023 7:48AM  
Home Health Quality Improvement Cardiac Rehab Video Playlist
This collection of videos, from the American College of Cardiology, the Centers for Medicare & Medicaid Services and other organizations, covers important information about cardiac rehab, including program basics and what patients should expect from participating in a CR program. These videos also include stories from patients who participated in CR programs.
Web link    Date Added: 01/11/2023    Date Last Modified: Jan 11 2023 7:50AM  
Fixed-Dose Combination Antyhypertensive Medication Coverage
This guide provides a state-by-state list of approved fixed-dose combinations of two or more medications used to treat hypertension.
Adobe PDF    Date Added: 09/30/2022    Date Last Modified: Sep 30 2022 7:41AM  
Smoking and Tobacco Use: Clinical Cessation Tools
This website, maintained by the Centers for Disease Control and Prevention, lists evidence and clinical guidelines for treating tobacco use and dependence. Providers will also find usable tools to guide their practice and help them integrate tobacco treatment into routine clinical care.
Web link    Date Added: 05/09/2022    Date Last Modified: May 9 2022 8:26AM  
Smoking and Tobacco Use: Clinical Education and Training
It's important to talk to patients about quitting tobacco use. If providers aren't sure how to start the conversation, this website has resources to help them.
Web link    Date Added: 05/09/2022    Date Last Modified: May 9 2022 8:31AM  
Treating Tobacco Use and Dependence: 2008 Update
Tobacco dependence is recognized as a chronic disease, one that typically requires ongoing assessment and repeated intervention. In this update on previously published guidelines, the Tobacco Use and Dependence Guidance Panel notes that the most effective way to help tobacco users quit is to provide them with information about multiple effective treatment options.
Web link    Date Added: 05/09/2022    Date Last Modified: May 9 2022 8:34AM  
Quick Reference Guide for Clinicians: 2008 Update Treating Tobacco Use and Dependence
This guide summarizes the strategies for helping people end their dependence on tobacco, published in full in Treating Tobacco Use and Dependence: 2008 Update. The guide includes an easy-to-follow "5A's" model for treating tobacco use and dependence
Adobe PDF    Date Added: 05/09/2022    Date Last Modified: May 9 2022 8:40AM  
Unlock a Life Without Tobacco
This is a patient information resource from QuitAssist®. Refer patients to this website so they can review the "5 Keys for Quitting."
Web link    Date Added: 05/09/2022    Date Last Modified: May 9 2022 8:43AM  
Cessation Materials for State Tobacco Control Programs
This website features materials for state tobacco control programs from the Centers for Disease Control and Prevention's Office on Smoking and Health.
Web link    Date Added: 05/09/2022    Date Last Modified: May 9 2022 8:45AM  
Tools & Tips from smokefree.gov: Articles & Information
This is a patient information resource from smokefree.gov. Refer patients to this website so they can review the different tools that can help them quit their tobacco use.
Web link    Date Added: 05/09/2022    Date Last Modified: May 9 2022 8:48AM  
WHO global report on trends in prevalence of tobacco use 2000-2025, third edition
This report presents the World Health Organization's estimates of tobacco use prevalence, numbers of users, and changes between 2000 and 2018, projected to 2025. Estimates are at global, regional and country levels.
Web link    Date Added: 05/09/2022    Date Last Modified: May 9 2022 8:51AM  
Tobacco Cessation
The Lung Association is a leader in the area of tobacco cessation policy at the federal, state and local levels. This website includes resources to assist states in achieving smoking cessation goals, along with information about tobacco cessation coverage policy and health systems change.
Web link    Date Added: 05/09/2022    Date Last Modified: May 9 2022 8:49AM  
Cardiac Rehabilitation, What is Cardiac Rehabilitation? (Infographic)
The American College of Cardiology's patient engagement program, CardioSmart, developed this infographic that providers can share with patients who may benefit from cardiac rehabilitation.
Adobe PDF    Date Added: 05/06/2022    Date Last Modified: May 6 2022 9:13AM  
Which CAD patient should be referred for cardiac rehabilitation?
Published in CardiologyAdvisor, this article describes the benefits of cardiac rehabilitation (CR) and identifies some of the barriers to ensuring patients participate in a CR program.
Web link    Date Added: 05/06/2022    Date Last Modified: May 6 2022 9:21AM  
Cardiac Rehabilitation Increasing Your Patient’s Life Expectancy
This presentation from HCA Midwest Health makes a case for cardiac rehabilitation (CR). Among the statistics shared: Patients who have completed a CR program can increase their life expectancy for up to five years.
Adobe PDF    Date Added: 05/06/2022    Date Last Modified: May 10 2022 2:50PM  
Referral to and discharge from cardiac rehabilitation: key informant views on continuity of care
This article, published in the National Library of Medicine, presents research results from a study conducted by the Canadian Institutes of Health Research. Enhancing communication emerged as the key factor in continuity of care and referral to cardiac rehabilitation programs.
Web link    Date Added: 05/06/2022    Date Last Modified: May 6 2022 9:19AM  
Heart of Health Policy: Cardiac Rehabilitation Obstacles and Opportunities
Only a fraction of eligible patients in the U.S. enroll in a cardiac rehabilitation (CR) program after a major cardiovascular event or diagnosis. This article, published in Cardiology Magazine, discusses how to overcome barriers to CR program enrollment.
Web link    Date Added: 05/06/2022    Date Last Modified: May 6 2022 9:24AM  
Medline Plus, Trusted Health Information for You: Cardiac Rehabilitation (Patient Resources)
Providers can refer patients eligible for cardiac rehabilitation to this website, maintained by the National Library of Medicine, for a comprehensive list of heart-health resources.
Web link    Date Added: 05/06/2022    Date Last Modified: May 10 2022 3:09PM  
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  
Rehab Select – The Four Cardiac Rehab Phases (Patients and Families)
This blog post from Rehab Select describes the four stages of cardiac rehabilitation (CR) so patients and family members know what to expect during each phase. The post also includes the goals typically set for each CR phase.
Web link    Date Added: 05/06/2022    Date Last Modified: May 6 2022 9:16AM  
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  
A Practical Guide to Help Your Patients Quit Using Tobacco
The CDC published this guide to give clinicians a simple and quick intervention strategy (three-to-five minutes) to use with patients who smoke or use other tobacco products.
Adobe PDF    Date Added: 05/04/2022    Date Last Modified: May 4 2022 8:17AM  
Integrating Tobacco Cessation into Electronic Health Records: Promising Practices and Lessons Learned
Electronic health records (EHRs) can be a valuable tool for providers when advising and assisting patients who want to quit smoking. The American Lung Association published this six-page paper to share promising practices and lessons learned for those who want to work with health systems to integrate or improve tobacco cessation into EHRs.
Adobe PDF    Date Added: 05/04/2022    Date Last Modified: May 4 2022 8:19AM  
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  
Tobacco Cessation Intervention List
Download this two-page handout the TMF Quality Innovation Network developed to help clinicians identify patients who need tobacco cessation support and then provide treatment to those who are tobacco users.
Adobe PDF    Date Added: 05/03/2022    Date Last Modified: Aug 9 2022 1:51PM  
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  
Cardiac Rehabilitation 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 understand how to manage their heart health.
Adobe PDF    Date Added: 04/29/2022    Date Last Modified: Apr 29 2022 8:32AM  
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  
How to Find Cardiac Rehabilitation Programs in the United States Using the CDC Interactive Atlas of Heart Disease and Stroke
Use these instructions to learn how to navigate the CDC’s Interactive Atlas of Heart Disease and Stroke when looking for data related to CR facilities in the United States.
Adobe PDF    Date Added: 04/29/2022    Date Last Modified: Apr 29 2022 1:45PM  
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  
Patient Fact Sheet: What is Cardiac Rehabilitation?
Health care providers are encouraged to give this two-page handout to patients who need CR and their caregivers to help them understand the benefits of CR and what to expect when participating in a CR program.
Adobe PDF    Date Added: 04/29/2022    Date Last Modified: Apr 29 2022 1:41PM  
Physician Order Form for Cardiac Rehab - Spanish
Providers can use this form when they want to refer Spanish-speaking patients to cardiac rehabilitation.
Adobe PDF    Date Added: 07/27/2023    Date Last Modified: Jul 27 2023 9:03AM  
Heart Failure Toolkit - Spanish
Share this fact sheet from the TMF Quality Innovation Network to help Spanish-speaking patients better manage heart failure (HF), also known as congestive heart failure (CHF).
Adobe PDF    Date Added: 05/01/2023    Date Last Modified: Apr 27 2023 1:28PM  
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  
Hypertension Toolkit, Spanish
Share this toolkit from the TMF Quality Innovation Network to help Spanish-speaking patients better manage hypertension, also known as high blood pressure.
Adobe PDF    Date Added: 11/11/2024    Date Last Modified: Nov 11 2024 9:53AM  
Cardiac Rehabilitation Medicine Tracker - Spanish
This tool can help Spanish-speaking cardiac rehabilitation patients keep track of their medications.
Adobe PDF    Date Added: 01/11/2023    Date Last Modified: Jan 11 2023 7:47AM