Million Hearts® Hospital/Health System Recognition Progr

ATTACHMENT 2a

DATA COLLECTION TOOL

Million Hearts® Hospital/Health System Recognition Program Application

Form Approved

OMB No. 0920-XXXX

Exp. date xx/xx/xxx

Million Hearts® Hospital / Health System Recognition Program Application

Public reporting burden of this collection of information is estimated at 2 hours and 40 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, NE, M/S D74, Atlanta, GA 30333, ATTN: PRA 0920-xxxx.

Requirements – Applicants must address:

• Three of the four priority areas

• A minimum of one strategy in each selected priority area, but are encouraged to target as many strategies as is appropriate for their institution

For each strategy selected, applicants must indicate their phase of implementation:

• Committing to implement (not yet begun, but can demonstrate plans to do so)

• Are currently implementing (have begun to address a given strategy, but do not yet have results)

• Have achieved outcomes/results (have outcomes resulting from addressing a given strategy)

The application is summarized in the grid below. Recommended attestation and data submissions for those achieving results are outlined for each strategy within the application. However, if a hospital or health system has another method by which it has documented and tracked success/outcomes, they can submit those for consideration.

Priority Area	Strategy	Phase
Priority Area 1: Keeping People Healthy	Food service guidelines Air quality policies Physical activity programs Employee benefit design	For each strategy, applicants will need to indicate their current phase of implementation: Committing Implementing Achieving
Priority Area 2: Optimizing Care	Referral to cardiac rehabilitation programs Initiation of cardiac rehabilitation Aspirin use Blood pressure control Cholesterol management Smoking cessation
Priority Area 3: Improving Outcomes for Priority Populations	Blacks/African-Americans with hypertension 35-64 year olds People who have had a heart attack or stroke People with mental and/or substance use disorders who use tobacco Other priority population
Priority Area 4: Innovating for Health	Describe innovations

Those that are able to demonstrate they have achieved successful outcomes for a given strategy may become the focus of promotional activities (e.g., e-newsletter, website, press announcements).

Website directions: List each Priority Area, the aim, and directions, as well as each strategy on a starting screen. Then for each strategy selected, applicants will have an individual, subsequent screen that lists the requirements and allows for attestation submission.

Priority Area 1: Keeping People Healthy

Aim: Create a healthy environment for patients, staff, and visitors

Directions: Applicants should select at least one strategy within this priority area which they are addressing and indicate the corresponding phase of activity (Committing, Implementing, or Achieving). The documentation requested to demonstrate each phase of activity should be submitted separately.

☐ Strategy 1: Adopt and implement food service guidelines in one or more areas where food is served in the hospital, such as inpatient meals, employee and visitor cafeterias, and/or vending machines/snack shops/micro-markets. These guidelines should be at least as rigorous as the Food Service Guidelines for Federal Facilities.

• _____Committing to implement this strategy: provide your plans to support this effort, including target population(s), policy or program materials, leadership support, timeframe, and measures you plan to track.

• _____Required attestation for those implementing: a copy/link to/of the policy supporting this strategy and date of adoption; timeline for implementation in food service operations; and estimated impact on food purchasing patterns due to the Food Service Guidelines Policy. Note, Food Service Guidelines standards included in food procurement agreements, food service contracts or permits, and/or formal organizational policies will count as evidence of implementation.

• _____Recommended outcomes for those achieving results: data showing increased sales of healthier food and beverage offerings, improved patient/employee consumption outcomes, and/or increased purchasing of healthier and reduced sodium items.

☐ Strategy 2: Adopt policies and practices to ensure healthy air quality for patients, visitors, and staff, staff, such as tobacco-free campus, no idling policies, education on poor air quality impacts, posting of local Air Quality Index (AQI).

If Committing to implement a strategy: provide your plans to support these healthy air related efforts, including target population(s), policy or program materials, timeframe, and measures you plan to track

If Implementing a strategy: documentation of implementation of selected healthy air strategies, including copies of the policy supporting each. Please also describe your plan for communicating information about the strategy to employees, patients, families, and others.

To qualify for Achieving result, applicants must submit attestation of implementation of all four air quality-related strategies in lieu of air quality outcomes data

Select at least 1 policy / practice	Indicate the phase for each selected policy / practice (drop down menu for each of 4 policies)
☐ Adopt and implement a tobacco-free campus policy that prohibits the use of all tobacco products, including electronic cigarettes and other types of electronic nicotine delivery systems, in buildings and hospital grounds (see http://www.noacc.org/documents/OhioTobaccoPolicyInfo.pdf for tobacco-free campus model policy)	_____Committing _____ implementing
☐ No-idling policies for patient drop-offs and deliveries	_____Committing _____ implementing
☐ Education for patients, families, employees, and/or clinical teams about the impact of and actions to mitigate poor air quality in and around the clinical institution (see https://millionhearts.hhs.gov/tools-protocols/tools/particle-pollution.html)	_____Committing _____ implementing
☐ Posting of local Air Quality Index (AQI) onsite (e.g. through the EPA Air Quality Flag Program or some other means of posting and sharing the AQI such as through waiting room videos, daily updates on community bulletin boards, links on hospital websites, patient discharge information)	_____Committing _____ implementing

☐ Strategy 3: Lead or support walking and other physical activity programs onsite and/or in the community for patients, visitors, and/or employees (see https://millionhearts.hhs.gov/tools-protocols/tools/physical-activity.html)

• _____Committing to implement this strategy: provide your plans to support this effort, including target population(s), policy or program materials, timeframe, and measures you plan to track.

• _____Required attestation for those implementing: documentation detailing the policy or practice supporting this program(s), program description, number of sites/programs conducted, dates of initiation, planned future program activities, and estimated impact on patient/employee health resulting from implementation

• _____Recommended outcomes for those achieving results: data showing improved adoption of physical activity as a result of implementing walking and other physical activity programs onsite and/or in the community; data detailing the number of people with increased hours of physical activity; increased physical activity rates of employees and/or community residents.

☐ Strategy 4: Use benefit design strategies outlined below to enhance employee health. Must select two of the six benefit design options listed on subsequent screens if selected.

Select at least 2 of the 6 benefit design options	Indicate the phase for each selected policy / practice (drop down menu for each of 6 benefit design options)
☐ Barrier-free access to hypertension and cholesterol medications, as well as to blood pressure (BP) monitors and/or cardiac rehabilitation (CR) participation. Access should exclude cost-sharing, prior authorization, and annual limits	_____Committing to implement this strategy: provide your plans to support this effort, including target population(s), policy or program materials, timeframe, and measures you plan to track. _____Required attestation for those implementing: copy of benefit design and estimated impact on employee health _____Recommended outcomes for those achieving results: data related to employee health benefit design such as improved BP measurements
☐ On-site BP monitoring	_____Committing to implement this strategy _____Required attestation for those implementing: description of BP monitoring program and estimated impact on employee health _____Recommended outcomes for those achieving results: data related to employee health benefit design such as improved BP measurements
☐ Regular and recurring promotion of benefits for tobacco cessation to patients and providers to increase awareness and use of covered treatments	_____Committing to implement this strategy _____Required attestation for those implementing: documentation of the corresponding communication / promotion plan, including estimated patient and provider views of promotion materials _____Recommended outcomes for those achieving results: data related to employee health benefit design such as utilization of tobacco cessation services
☐ A benefits package for employees that includes tobacco cessation counseling and FDA-approved cessation medications, including nicotine replacement therapy (NRT) and non-nicotine medications without insurance barriers such as cost-sharing, prior authorization, and annual limits on quit attempts	_____Committing to implement this strategy: provide your plans to support this effort, including target population(s), policy or program materials, timeframe, and measures you plan to track _____Required attestation for those implementing: documentation detailing tobacco cessation benefits, including costs sharing, prior authorization, and annual limits, as well as communication/promotion plan and access to data on employee utilization of benefits _____Recommended outcomes for those achieving results: data related to employee health benefit design such as utilization of tobacco cessation services
☐ A benefits package for employees that includes physical activity benefits such as, subsidized/discounted access to exercise facilities, organized individual/group physical activity programs, physical fitness assessments with follow-up counseling and recommendations, and free / subsidized self-management programs for physical activity	_____Committing to implement this strategy _____Required attestation for those implementing: documentation detailing physical activity benefits, including costs sharing, as well as communication/promotion plan and access to data on employee utilization of benefits _____Recommended outcomes for those achieving results: data related to employee health benefit design such as utilization of physical activity incentives
☐ Other, please specify. Submissions must have an impact on cardiovascular health _________________ ___________________________________________	_____Committing to implement this strategy: describe plans _____Required attestation for those implementing: documentation detailing the benefits _____Recommended outcomes for those achieving results: data related to the employee health benefit design

Priority Area 2: Optimizing Care

Aim: Help people prevent heart and kidney disease and stroke by achieving excellence in the ABCS (aspirin, blood pressure, cholesterol, smoking cessation) and cardiac rehabilitation (CR)

Directions: Indicate the strategies below in which Hospitals’ / Health Systems’ ambulatory primary care and relevant (cardiology, nephrology, endocrinology) specialty practices are working to improve / have improved performance, and identify the best practices implemented to do so.

Those that have just begun working in this priority area should commit to improve performance in one or more of the priorities below and identify the best practices they will implement.

Select the strategies in which you are committing to improve, are already working to improve, or have achieved improved performance:

☐ Strategy 1: Referral of eligible patients to cardiac rehabilitation programs (see https://millionhearts.hhs.gov/tools-protocols/tools/cardiac-rehabilitation.html)

• _____Committing to implement this strategy

• _____Required attestation for those implementing: documentation of baseline data for % eligible patients referred. Evidence of implementation, e.g., policy developed, work group established, workflow revised, timeline determined, target outcome levels identified

• _____Recommended outcomes for those achieving results: documentation of >80% referral of eligible patients

☐ Strategy 2: Initiation (attendance of first session) among those referred to cardiac rehabilitation (see https://millionhearts.hhs.gov/tools-protocols/tools/cardiac-rehabilitation.html)

• _____Committing to implement this strategy

• _____Required attestation for those implementing: documentation of baseline data for % referred patients who initiated CR. Evidence of implementation, e.g., policy developed to improve initiation, such as warm hand-offs, work group established, workflow revised, timeline determined, target outcome levels identified

• Recommended outcomes for those achieving results: documentation of >70% initiation among those referred

☐ Strategy 3: Aspirin use for secondary prevention

• _____Committing to implement this strategy

• _____Required attestation for those implementing: documentation of baseline, such as CMS Quality ID 204; CMS eMeasure ID 164; NQF 0068; CMS Shared Saving Program ACO-30; or equivalent. Evidence of implementation, e.g., policy developed, work group established, workflow revised, timeline determined, target outcome levels identified

• Recommended outcomes for those achieving results: documentation of >80% performance, such as on CMS Quality ID 204; CMS eMeasure ID 164; NQF 0068; CMS Shared Saving Program ACO-30; or equivalent

☐ Strategy 4: Blood Pressure Control (see https://millionhearts.hhs.gov/files/HTN_Change_Package.pdf)

• _____Committing to implement this strategy

• _____Required attestation for those implementing: documentation of baseline, such as CMS Quality ID 236; CMS eMeasure ID 165; NQF 0018; CMS Shared Saving Program ACO-28; or equivalent. Evidence of implementation, e.g., policy developed, work group established, workflow revised, timeline determined, target outcome levels identified

• Recommended outcomes for those achieving results: documentation of > 80% performance, such as on CMS Quality ID 236; CMS eMeasure ID 165; NQF 0018; CMS Shared Saving Program ACO-28; or equivalent

☐ Strategy 5: Cholesterol Management

• _____Committing to implement this strategy

• _____Required attestation for those implementing: documentation of baseline, such as CMS Quality ID 438; CMS eMeasure ID 347; or equivalent. Evidence of implementation, e.g., policy developed, work group established, workflow revised, timeline determined, target outcome levels identified.

• Recommended outcomes for those achieving results: documentation of >80% performance, such as on CMS Quality ID 438; CMS eMeasure ID 347; or equivalent

☐ Strategy 6: Smoking Cessation (see https://millionhearts.hhs.gov/files/Tobacco-Cessation-Action-Guide.pdf)

• _____Committing to implement this strategy

• _____Required attestation for those implementing: Required attestation: documentation of baseline, such as CMS Quality ID 226; CMS eMeasure ID 138; NQF 0028; Shared Savings Program ACO-17 The Joint Commission inpatient measures, or equivalent Evidence of implementation, e.g., policy developed, work group established, workflow revised, timeline determined, target outcome levels identified

• Recommended outcomes for those achieving results: documentation of >80% performance, such as on CMS Quality ID 226; CMS eMeasure ID 138; NQF 0028; Shared Savings Program ACO-17; The Joint Commission inpatient measures, or equivalent

In the space below, please describe the best practices you utilize in support of the chosen strategies, such as rewarding high-performing individual employees, using standard treatment protocols, etc.

Priority Area 3: Improving Health Outcomes for Priority Populations

Aim: Focus improvement efforts on specific subsets of the population with high disease burden and risk.

Directions: Select the priority population(s) on which you are focusing and corresponding strategies being employed. You may select more than one population. If you are targeting a population not listed below, please describe it and your strategies in Priority Area 4, Innovating for Health.

☐ Priority Population: Blacks/African-Americans with hypertension

Strategies:

☐ Guideline-based protocols

☐ Medication adherence strategies

☐ Community-based physical activity program enrollment

☐ Other, please specify:___________________________________________________________

☐ Priority Population: 35-64 year olds, the age group showing an increase in CV disease mortality

Strategies:

☐ Tailored protocols for hypertension, tobacco, and/or cholesterol management

☐ Community-based physical activity program enrollment

☐ Other, please specify:___________________________________________________________

☐ Priority Population: People who have had a heart attack or stroke

Strategies:

☐ Cardiac Rehabilitation: automated referrals, hospital CR liaisons, referrals to convenient locations

☐ Education on avoiding exposure to air particle pollution: Air Quality Index tools

☐ Other, please specify:___________________________________________________________

☐ Priority Population: People with mental and/or substance use disorders who use tobacco

Strategies:

☐ Integrating tobacco cessation into behavioral health treatment

☐ Tobacco-free mental health and substance use treatment campus policies

☐ Tailored quitline protocols

☐ Other, please specify:___________________________________________________________

_____For those committing to implement: Within the description below, please provide your plans to support this effort, including the size of target population(s), policy or program materials, timeframe, and measures you plan to track

_____Required attestation for those implementing: Within the description below, please provide documentation supporting the efforts, such as the size of the target populations, policy or program materials, timeframe, and measures being tracked

_____Recommended outcomes for those achieving results: Within the description below, please include the size of the target population(s), and provide data on performance measures which demonstrate the results you have achieved in these target priority populations

Describe (max 500 words) the strategies (listed under each priority population) you are employing and outcomes you have achieved/are working towards with this population(s): __________________________________________________________________________________________

__________________________________________________________________________________________

Priority Area 4: Innovating for Health

Aim: Improve cardiovascular health outcomes through innovative approaches, which differ from and/or go beyond the strategies listed in Priority Areas 1-3.

Directions: In the space below, describe an innovative approach you intend to or currently are undertaking in support of the Million Hearts objectives listed below (please reference the Million Hearts webpage – www.millionhearts.hhs.gov – for additional strategies; updated regularly). Please share the impact you plan to or have already achieved, as we are interested in a variety of approaches to improving care.

The innovative strategies implemented should advance the following Million Hearts® objectives:

• 20% reduction in sodium consumption

• 20% reduction in tobacco use

• 20% reduction in physical inactivity

• 80% performance on the ABCS measures among ambulatory primary care and relevant (cardiology, nephrology, endocrinology) specialty practices

• 70% initiation rate among those referred to cardiac rehab

• Increase patient engagement in heart healthy behaviors

Innovative examples include behavioral design strategies supporting increased healthy food consumption, specific outreach and support services such as barbershop initiatives to improve HTN control, etc.

_____For those committing to implement: Within the description below, please provide your plans to support this effort, including description and size of target population(s), policy or program materials, timeframe, and measures you plan to track.

_____Required attestation for those implementing: Within the description below, please provide documentation supporting the efforts, such as the target population(s), policy or program materials, timeframe, and measures currently being tracked.

_____Recommended outcomes for those achieving results: data on performance measures which demonstrate the results you have achieved.

Describe (max 500 words) the strategies you are employing, the Million Hearts® objectives you are targeting, and the outcomes you have achieved: __________________________________________________________________________________________

__________________________________________________________________________________________

Summary: Please complete the following grid, summarizing your submission based on the above application. This summary of your commitment to Million Hearts® strategies will be publicly available upon vetting and approval. Please review once completed and confirm its accuracy.

As a reminder, you are required to implement a minimum of one strategy in three of the four Priority Areas, but are encouraged to target as many strategies as is appropriate for your institution. The following is a summary of the supporting evidence required per each phase:

• Committing – no data required other than your pledging to implement

• Implementing – must submit the data per strategy listed as “Required attestation for those implementing”

• Achieving – must submit the data per strategy listed as “Recommended outcomes for those achieving results”

Priority Area	Strategy (Highlight the strategies being addressed)	Committing, Implementing, Achieving (For each strategy, applicants will need to indicate their current phase of implementation: Committing, Implementing, Achieving)
Priority Area 1: Keeping People Healthy	Food service guidelines Air quality policies Physical activity programs Employee benefit design	1. 2. 3. 4.
Priority Area 2: Optimizing Care	Referral to cardiac rehabilitation programs Initiation of cardiac rehabilitation Aspirin use Blood pressure control Cholesterol management Smoking cessation	1. 2. 3. 4. 5. 6
Priority Area 3: Improving Outcomes for Priority Populations	Blacks/African-Americans with hypertension 35-64 year olds People who have had a heart attack or stroke People with mental and/or substance use disorders who use tobacco	1. 2. 3. 4.
Priority Area 4: Innovating for Health	Describe innovations
Additional selection (optional)
Additional selection (optional)

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