A Facilitator’s Primary Care Toolkit to Improve Heart Health

Resource: ABCS Toolkit for the Practice Facilitator (PDF, 20.4 MB, 176 pages)

This toolkit introduces the ABCS of heart health—aspirin use by high-risk individuals, blood pressure control, cholesterol management, and smoking cessation—and provides checklists, action plans, and other guidance for primary care practices implementing evidence-based guidelines, transforming health care delivery, and improving patients’ heart health. Designed for use by practice facilitators, these tools can help practices move forward on a variety of key drivers and change strategies.

Tool from ABCS Toolkit Description Applicable Part of EvidenceNow Model
Entire Toolkit See above Practice Facilitation Skills for Working with Practices
Aspirin Use Care: Tasks for the Practice Facilitator, p. 12 Checklist to increase aspirin use for secondary prevention of cardiovascular disease ABCS of Heart Health: Aspirin Use by High Risk Individuals
Blood Pressure Control: Tasks for the Practice Facilitator, pp. 18–21 Checklist to address blood pressure control ABCS of Heart Health: Blood Pressure Control
Cholesterol Management: Tasks for the Practice Facilitator, pp. 62-63 Checklist to address blood pressure control ABCS of Heart Health: Cholesterol Management
Smoking Cessation: Tasks for the Practice Facilitator, pp. 76-77 Checklist to increase the rate of smoking cessation counseling for patients who smoke ABCS of Heart Health: Smoking Cessation
Smoking Cessation Treatment Guide, p. 84 Guide on how to identify and treat patients who smoke as an example of adapting guidelines into treatment protocols Select and customize evidence for practice-wide implementation
How to Add a Medication Questionnaire by Creating Structured Data in eClinicalWorks, pp. 46-48 Example of how to modify practices’ electronic health records (EHR) to reinforce following clinical guidelines Embed selected evidence and guidelines into clinical information systems
Blood Pressure M.A.P. IT Tools: Act Rapidly, pp. 37-42 Assessment tool to measure the extent to which practices detect patients’ elevated blood pressure but fail to intervene, and Solutions tool to identify evidence-based ideas for action Adopt a consistent quality improvement (QI) approach and use QI tools to make changes
Prevention and Care Dashboard, pp. 112–141 Dashboard demonstrates how an EHR dashboard can track QI data to show trends and assess progress toward practice goals for heart health and other important screening and benchmarks ABCS of Heart Health, Adopt a consistent QI approach and use QI tools to make changes, Engage care teams and other staff to support implementation of new evidence, Create dashboard reports for selected measures
Hypertension Panel Summary, pp. 144-145 EHR dashboard showing how to track QI data show trends and assess progress toward practice goals Select internal QI measures, collect data, compare with goals and benchmarks, and act on data regularly; Engage care teams and other staff to support implementation of new evidence; Create dashboard reports for selected measures
Clinical-Community Program Linkages Workflow Best Practices, p. 156 Decision tree helps identify patients that qualify for referral to evidence-based interventions for self-management support of chronic conditions Establish workflows that identify and engage patients affected by changing evidence; Link patients and families with community resources to assist them in implementing evidence-based care plans and meeting their health goals
How Community Pharmacists Can Help with the Common Reasons for Non-Adherence, pp. 164-165 Resource helps community pharmacists use medication therapy management to address common reasons that patients do not follow medication instructions Support patient and family engagement in their own evidence-based care; Link patients and families with community resources to assist them in implementing evidence-based care plans and meeting their health goals
Medication Therapy Management (MTM) Fact Sheet and FAQ, pp. 166-168 Fact Sheet describes what MTM is and answers questions frequently asked by patients Support patient and family engagement in their own evidence-based care
Medication Therapy Management (MTM) Patient Brochure, p. 169 Brochure reviews advantages of receiving MTM Support patient and family engagement in their own evidence-based care

Institution of origin: New York City Department of Health and Mental Hygiene

Permissions: Used with permission of the New York City Department of Health and Mental Hygiene, a partner of the New York University (NYU) School of Medicine.

Acknowledgements: NYU School of Medicine, Healthy Hearts NYC, Agency for Healthcare Research and Quality EvidenceNOW Initiative

Publication date: 2016

Go to EvidenceNOW Tools for Change to search for other tools to help primary care practices implement the best evidence.

Go to the ABCS of Heart Health page for more PCOR evidence used in EvidenceNOW.

Go to Practice Facilitation Skills for Working with Practices to find more tools for practice facilitators.

Page last reviewed November 2018
Page originally created August 2018
Internet Citation: A Facilitator’s Primary Care Toolkit to Improve Heart Health. Content last reviewed November 2018. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/evidencenow/heart-health/overall/dashboard.html
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