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www.ahrq.gov/topics/practice-improvement.html
Practice facilitation, sometimes also referred to as quality improvement coaching, is an approach to
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www.ahrq.gov/takeheart/about/initiative/partner-hospitals/lee-health.html
November 01, 2022 - TAKEheart's workflow mapping exercise helped our team discover that patients were not consistently being referred … (1) the failure of some physicians to make referrals to CR and (2) the problem of patients who were referred … To improve enrollment of referred patients, Harris-Barter's team realized the importance of maximizing
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www.ahrq.gov/prevention/resources/chronic-care/ccrm-atlas-suppl/ccrm-apptabA-17.html
October 01, 2013 - Measure 14: Patients referred to a community health educator referral liaison (CHERL)
Previous … Measure 14: Patients referred to a community health educator referral liaison (CHERL)
A-18. … CCRM Atlas Measure 14: Patients referred to a community health educator referral liaison (CHERL)
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/getting-started-slides.pptx
December 31, 2022 - lack of coordination even if they are referred. … - Which patients currently referred?
- Are some diagnoses missing? … - Who decides which patients are referred? … Who is referred to cardiac rehabilitation and why? … Who decides which patients are referred?
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-4-slides.pdf
August 19, 2021 - participation
Aggregate Data: population
specific
• # of patients eligible for CR
• # of patients referred … patients who enroll or don’t enroll
Patient -level Shows which specific patients were (or were not) referred … eligible patients at discharge Provides information about the
pool of potential patients
Patients referred … Monthly to start
Enrollment Measure
21
PARTICIPANTS
REFERRAL
MEASURE
Numerator:
Number of referred … HF participation is low, accounting for only 2% of your Phase II volume
• HF patients are primarily referred
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-7-slides.pdf
November 18, 2021 - to CR are identified
- All patients with exclusion criteria are not being referred
- Referrals are … Indicator Name Description Numerator/Denominator
Referral Initiation Proportion of clients referred … from initiating service
# of clients referred from initiating service
__________________________ … that complete referral at
receiving service
# of referred clients seen at referring service
___ … _________________________________
# of clients referred from initiating service
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-5-slides.pdf
December 31, 2022 - Referral built into an order set
Default, “opt-out” model
All patients with qualifying diagnosis are referred … why bother
Uncertainty about who is responsible for making the referral or if someone has already
referred … order set
Uncertainty about who is responsible
for making the referral or if someone
has already referred … 2)
Example Aim Statement:
We aim to increase the number of patients with MI, PCI and CABG who are referred … to CR are identified
- All patients with exclusion criteria are not being referred
- Referrals are going
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-6-implementation-guide.pdf
June 02, 2025 - Automatic referral is designed to
ensure that all eligible patients are identified and referred to CR … Why this Misconception Matters: If you ignore the needs of patients before they are
referred, you will … Care coordination on behalf of patients before they are referred includes
working with physicians and … processes and activities designed and systematically executed to help
ensure eligible patients get referred … • Knowing which subpopulations of eligible patients are not being referred.
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-4-implementation-guide.pdf
September 01, 2021 - • Process: reflects the specific action(s) taken, for example, providing each referred patient a letter … AR implementation and
outreach to cardiologists has increased the number of referred patients. … You may not have even spoken to people
that were just referred at the end of the month. … You may be tracking the percent of eligible patients that were referred to CR. … If this happens, your numerator may leave out patients that actually were
referred.
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA205-Materials_II.pdf
June 02, 2025 - families do not follow through with referrals, families often do not understand where
they are being referred … more children are being identified and linked to services
as feedback on eligibility status of the referred … a child's ability to function in many settings, it is
important that children who fail screens are referred … using "Speech/Language Pathologist User
Defined QDM Value Set (1.1.1.1)"
"Patient Care Experience: Referred … for follow-up services but did not continue care in the medical home
where diagnosed" using "Referred
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-5-implementation-guide.pdf
June 02, 2025 - order set in such a way that all patients with a qualifying diagnosis for cardiac
rehabilitation are referred … CR referral process measures require a verbal
conversation between the ordering clinician and the referred … Patients to include
All patients with an agreed-upon set of codes should be automatically referred/opted … • Ensure that all eligible patients are referred unless the clinical provider takes action to stop … You will need to decide
whether any such patients should be referred or
whether they should be flagged
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www.ahrq.gov/prevention/resources/chronic-care/ccrm-atlas-suppl/ccrm-atlas3-6.html
October 01, 2013 - Measure 14: Patients referred to a community health educator referral liaison (CHERL)
A-18. … Potential Measure UU
Item
Description
Title
Percentage of clients referred to a community … received appropriate preventive services
Description
This measure assesses whether clients referred … This measure should focus on the delivery of preventive services for which the patients were referred … This measure will be assessing community resource proactivity in working with clients who have been referred
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide87.html
October 01, 2014 - Every tobacco user should be offered at least a minimal intervention whether or not he or she is referred
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www.ahrq.gov/prevention/resources/chronic-care/ccrm-atlas-suppl/ccrm-apptabA-20.html
October 01, 2013 - Measure 14: Patients referred to a community health educator referral liaison (CHERL)
A-18. … This measure calculated the proportion of all patients with risk factors referred for intensive counseling … behavior and engaged to address the unhealthy behavior (A1-A3)
Numerator:
Number of patients referred
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-3-implementation-guide.pdf
June 02, 2025 - Develop a standard process for informing an external CR program of a referred
patient. … Which patients are currently referred for cardiac rehabilitation, i.e., what diagnoses? … Who decides which patients are referred?
What is the patient referral process? … The example fishbone diagram captures common causes eligible patients
fail to be referred into CR. … If
your program does not know a patient is eligible then they will not be referred.
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www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/strategy6g-rapid-referral.html
April 01, 2023 - confidence, and dissatisfaction with their PCP. 1
"Patients are often informed that they will be 'referred … ' but have little or no influence on the process or knowledge about who they will be referred to or how … guidelines is to identify which clinical conditions the PCPs should manage themselves and which should be referred … them are more obvious: more effective care for patients, higher relative value units (RVUs), and more referred
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www.ahrq.gov/takeheart/assessing/summary/index.html
August 01, 2023 - Trust (HRET) of the American Hospital Association (AHA) and Crosby Marketing Communications, further referred
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/getting-started-resource-guide.pdf
March 01, 2023 - • Which patients are currently referred for cardiac rehabilitation, i.e., what diagnoses? … • Who decides which patients are referred?
• What is the patient referral process? … The example fishbone diagram
captures common reasons why eligible patients fail to be referred into … Number of patients referred to
CR
Dividing the number of patients who enroll by the number referred … Number of patients enrolled in
CR
Dividing the number of patients who enroll by the number referred
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www.ahrq.gov/ncepcr/tools/obesity/obpcp-tool12.html
May 01, 2014 - Clinic Name]
This is how many times I visited:
___________________________________________
(referred
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www.ahrq.gov/ncepcr/care/coordination/atlas/chapter4tab5.html
June 01, 2014 - specifications available: No
PCP communicates to patient the reason for referral l
Number of referred … family)
eMeasure specifications available: No
PCP review of Specialist Report l
Number of referred … caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred