0920-1274 Million Hearts® Hospitals & Health Systems Recognition P

Million Hearts® Hospital/Health System Recognition Program

1274 Att 2b Updated Data Coll Tool

OMB: 0920-1274

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ATTACHMENT 2b

UPDATED DATA COLLECTION TOOL

Million Hearts® Hospitals & Health Systems Recognition Program Application

Million Hearts® Hospitals & 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 0920-1274.

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: Building Healthy Communities	Policies to decrease particle pollution exposure Programs to decrease physical inactivity Food service guidelines	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 and anticoagulant use Blood pressure control Cholesterol management Smoking cessation
Priority Area 3: Focus on Health Equity through Priority Populations	People from racial / ethnic minority groups Pregnant and postpartum women with hypertension People with lower incomes People who live in rural areas or other ‘access deserts’ People with behavioral health issues who use tobacco Other priority population
Priority Area 4: Supplemental programs and innovations	Describe supplemental efforts and/or 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:Building Healthy Communities

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 policies and practices to decrease particle pollution exposure for patients, visitors, and/or 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 particle pollution exposure 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 ‘Create a Supportive Environment for Cessation’ section of Change Package for model policies: https://millionhearts.hhs.gov/files/tobacco_cessation_change_pkg.pdf#page=13)

_____Committing

_____ Implementing

_____ Achieving

☐ No-idling policies for patient drop-offs and deliveries

_____Committing

_____ Implementing

_____ Achieving

☐ 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

_____ Achieving

☐ 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

_____ Achieving

☐ Strategy 2: Lead or support programs to decrease physical inactivity, such as walking and other physical activity programs onsite and/or in the community for patients, visitors, and/or employees, availability of peer support groups, supporting / providing safe spaces for physical activity, supporting and participating in community complete streets, etc. (see Physical Activity | Million Hearts® (hhs.gov)

_____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 3: 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.

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 or improvement of 20% over several years

☐ 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 or improvement of 20% over several years

☐ Strategy 3: Aspirin and anticoagulant 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 or improvement of 20% over several years

☐ 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 or improvement of 20% over several years

☐ 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 or improvement of 20% over several years

☐ 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 138v8b; 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 138v8b (please note, this is a 3-part measure, but this designation is focused on 80% performance on part b: tobacco users who receive cessation intervention); NQF 0028; Shared Savings Program ACO-17; The Joint Commission inpatient measures, or equivalent or improvement of 20% over several years

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. (max of 500 words)

Priority Area 3: Focusing on Health Equity to Improve 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 the 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: People from Racial / Ethnic Minority Groups

☐ Develop deliberate strategy or approach to improve hypertension management for people of racial ethnic minority groups such as Medication Therapy Management (MTM), Self Measured Blood Pressure Monitoring (SMBP) held in trusted spaces (barbershops, salons, faith-based organizations, etc.) Resource: https://www.nachc.org/wp-content/uploads/2021/09/BPAA-Roadmap_08252021.pdf

☐ Medication adherence / intensification strategies

Scale/spread the systematic use of tailored protocols

☐ Enhance sodium reduction

☐ Support policies that prohibit the sale of flavored tobacco products, including menthol