Module 6: Laying the Groundwork for Care Coordination

Video: Laying the Groundwork for Care Coordination (1:00:12)

Slides: Laying the Groundwork for Effective Care Coordination (PDF, 1.4 MB)

Implementation Guide: Laying the Groundwork for Effective Care Coordination (PDF, 484 KB)

This module demonstrates the broad reach of care coordination. It gives guidance on assessing current care coordination and provides direction on redesigning care coordination processes to make them more effective.

Topics covered in this module include:

• An overview of care coordination and its application to cardiac rehab.
• Defining a completed referral.
• Understanding the characteristics of the population to better meet patient needs and concerns.
• Assessing current care coordination to identify gaps and opportunities.
• Setting priorities and planning for changes in care coordination.

Suggested Audience

The target audiences for this session include:

• The CR QI team
• 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:

• Explain why implementing effective care coordination benefits CR patients.
• Assess the effectiveness of current care coordination workflow processes for inpatient CR to outpatient CR, especially the transition between the two settings.
• Understand how to establish priorities for enhancing care coordination to better meet patient needs to improve enrollment and participation in CR.

Speaker Bios

Provide feedback on this training module at TAKEheart@abtassoc.com.

Related Resources

American Association of Cardiovascular and Pulmonary Rehabilitation. Commercial Insurance Pre-Authorization Template for Cardiac Rehabilitation. Accessed August 31, 2021.

American Association of Cardiovascular and Pulmonary Rehabilitation. Ambassador Program at the Miriam Hospital Cardiac Rehabilitation. Accessed August 31, 2021.

American Association of Cardiovascular and Pulmonary Rehabilitation. Reduce Cost-Sharing Barriers for CR Services with Creative Options. Accessed August 31, 2021.

American Association of Cardiovascular and Pulmonary Rehabilitation. Cardiac Rehabilitation Pre‐Enrollment Group Screening. Accessed August 31, 2021.

American Association of Cardiovascular and Pulmonary Rehabilitation. AACVPR Case Study: Genesis Health System. Accessed August 31, 2021.

Genesis Healthcare System. Welcome to Heart & Vascular Pulmonary Rehabilitation. Accessed August 31, 2021.

American Association of Cardiovascular and Pulmonary Rehabilitation. Cardiac Accelerated Use of Cardiac Rehabilitation. Accessed August 31, 2021.

American Association of Cardiovascular and Pulmonary Rehabilitation. Matching Capacity to Demand: Open Gym. Accessed August 31, 2021.

American Association of Cardiovascular and Pulmonary Rehabilitation. AACVPR Case Study: Southwest Florida Heart Group. Open Gym Concept. Accessed August 31, 2021.

American Association of Cardiovascular and Pulmonary Rehabilitation. AACVPR Case Study: Mount Carmel Health System. Cardiac Rehab Open Gym. Accessed August 31, 2021.

American Association of Cardiovascular and Pulmonary Rehabilitation. AACVPR Case Study: Christiana Care Health System. Use Clinician Follow-up to Bolster Enrollment. Accessed August 31, 2021.

American Association of Cardiovascular and Pulmonary Rehabilitation. Cardiac Rehabilitation Patient Progress Report. Accessed August 31, 2021.

American Association of Cardiovascular and Pulmonary Rehabilitation. Incorporating Motivational and Financial Incentives. Accessed August 31, 2021.

American Association of Cardiovascular and Pulmonary Rehabilitation. AACVPR Case Study: University of Vermont. Financial Incentives to Improve Cardiac Rehabilitation Attendance Among Medicaid Enrollees. Accessed August 31, 2021.

American Association of Cardiovascular and Pulmonary Rehabilitation. Use of Text Messaging and Mobile Applications. Accessed August 31, 2021.

American Association of Cardiovascular and Pulmonary Rehabilitation. Ambassador Program at the Miriam Hospital Cardiac Rehabilitation. Accessed August 31, 2021.