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Implementing Effective Care Coordination
Overview
This module provides guidance on implementing changes to enhance care coordination efforts. It gives direction on changing workflow processes to adopt a patient-centered approach to care. The module also discusses the need to engage staff in the redesign and take time to document and orient staff to new procedures and protocols. Lastly, there is a brief discussion of monitoring and refining care coordination enhancements.
Topics covered in this module include:
- Review of care coordination concepts.
- Discussion of addressing patient needs and concerns.
- Changing workflow processes including documenting changes, training, and orienting staff.
- Monitoring and using data to support care coordination.
Suggested Audience
The target audiences for this session include:
- The CR QI team
- Representatives of QI and data analytics teams
- Non-team cardiac clinicians
- Discharge planners
- Care coordinators
- Hospital leadership
It is important to note that the audiences listed above are a suggestion rather than a limitation. All are welcome to watch and review the module.
Learning Objectives
Upon completion of this module, attendees should be able to:
- Understand how to redesign care coordination to better meet patient needs to improve enrollment and participation in CR.
- Develop training and policy materials to facilitate care coordination enhancements.
- Monitor and use data to determine effectiveness of the care coordination redesign and inform future refinements.
Speaker Bios
Vermont Center on Behavior and Health
Brigham and Women’s Hospital
Provide feedback on this training module at TAKEheart@abtassoc.com.
Related Resources
American Association of Cardiovascular and Pulmonary Rehabilitation. Cardiac Rehabilitation Pre‐Enrollment Group Screening. https://www.aacvpr.org/Portals/0/Million%20Hearts%20Change%20Package/4.18.2018%20Files/EP-26-CRCP-Turnkey-Pre-Enrollment%20Group%20Screening.pdf. Accessed October 25, 2021.
American Association of Cardiovascular and Pulmonary Rehabilitation. AACVPR Case Study: Genesis Health System. https://www.aacvpr.org/Portals/0/Million%20Hearts%20Change%20Package/4.24.2018%20Files/EP-27-CRCP-Case%20Study-Genesis%20Hospital-Group%20Orientation.pdf. Accessed October 25, 2021.
American Association of Cardiovascular and Pulmonary Rehabilitation. AACVPR Case Study: Genesis HealthCare System—Group Orientation. https://www.aacvpr.org/Portals/0/Million%20Hearts%20Change%20Package/4.18.2018%20Files/EP-27.5-CRCP-Group%20Orientation.pdf. Accessed October 25, 2021.
American Association of Cardiovascular and Pulmonary Rehabilitation. Accelerated Use of Cardiac Rehabilitation https://www.aacvpr.org/Portals/0/Million%20Hearts%20Change%20Package/4.24.2018%20Files/EP-30-CRCP-Turnkey-Accelerated-Usage%20of%20CR.pdf. Accessed October 25, 2021.
American Association of Cardiovascular and Pulmonary Rehabilitation. Matching Capacity to Demand: Open Gym. https://www.aacvpr.org/Portals/0/Million%20Hearts%20Change%20Package/4.25.2018%20Files/EP-33-CRCP-Turnkey-Open%20Gym.pdf. Accessed October 25, 2021.
American Association of Cardiovascular and Pulmonary Rehabilitation. AACVPR Case Study: Southwest Florida Heart Group. https://www.aacvpr.org/Portals/0/Million%20Hearts%20Change%20Package/4.25.2018%20Files/EP-34-CRCP-Case%20Study-Southwest%20FL%20Heart%20Group-Open%20Gym%20Model.pdf. Accessed October 25, 2021.
American Association of Cardiovascular and Pulmonary Rehabilitation. AACVPR Case Study: Mount Carmel Health System. https://www.aacvpr.org/Portals/0/Million%20Hearts%20Change%20Package/4.18.2018%20Files/EP-34.5-CRCP-Case%20Study-Mount%20Carmel.pdf. Accessed October 25, 2021.
American Association of Cardiovascular and Pulmonary Rehabilitation. AACVPR Case Study: Christiana Care Health System. https://www.aacvpr.org/Portals/0/Million%20Hearts%20Change%20Package/4.24.2018%20Files/EP-41-CRCP-Case%20Study-Christiana%20Care-Provider%20Follow%20Up.pdf. Accessed October 25, 2021.
American Association of Cardiovascular and Pulmonary Rehabilitation. Cardiac Rehabilitation Patient Progress Report. https://www.aacvpr.org/Portals/0/Million%20Hearts%20Change%20Package/4.18.2018%20Files/EP-43-CRCP-Turnkey-Participant%20Progress%20Report.pdf. Accessed October 25, 2021.
American Association of Cardiovascular and Pulmonary Rehabilitation. Incorporating Motivational and Financial Incentives. https://www.aacvpr.org/Portals/0/Million%20Hearts%20Change%20Package/4.18.2018%20Files/A-3-CRCP-Turnkey-Incorporating%20Motivational%20and%20Financial%20Incentives.pdf. Accessed October 25, 2021.
American Association of Cardiovascular and Pulmonary Rehabilitation. Financial Incentives to Improve Cardiac Rehabilitation Attendance Among Medicaid Enrollees. https://www.aacvpr.org/Portals/0/Million%20Hearts%20Change%20Package/4.11.2018%20Files/A-4-CRCP-Case%20Study-UVM%20Incentives.pdf. Accessed October 25, 2021.
American Association of Cardiovascular and Pulmonary Rehabilitation. Use of Text Messaging and Mobile Applications. https://www.aacvpr.org/Portals/0/Million%20Hearts%20Change%20Package/4.18.2018%20Files/A-5-CRCP-Turnkey-Use%20of%20Text%20Messaging.pdf. Accessed October 25, 2021.
American Association of Cardiovascular and Pulmonary Rehabilitation. AACVPR Case Study: Miriam Hospital Center. https://www.aacvpr.org/Portals/0/Million%20Hearts%20Change%20Package/4.18.2018%20Files/A-6-CRCP-Case%20Study-The%20Miriam%20Hospital%20CR%20Ambassador%20Program.pdf. Accessed October 25, 2021.
*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.
