Performance Measurement Accelerating Improvement (2006) / Chapter Skim
Currently Skimming:
Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman
Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman
Pages 250-286
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 250... ...
As such, performance in this area needs to be measured. Currently, there exists an array of promising measures that, if implemented nationally, could bring the requisite attention needed to stimulate quality improvement in transitional care, define accountability, realign financial incentives, and foster interoperable electronic health information systems.
|
From page 251... ...
But our health care delivery system, whether examined by payment, quality improvement initiatives, accreditation, performance measurement, or how clinicians define their practice, is increasingly setting-centered. In many respects, the term "health care system" is a misnomer.
|
From page 252... ...
The Robert Wood Johnson Foundationfunded Partnership for Solutions poll provides important insights. For the 125 million persons with chronic conditions in this country, there is a strong relationship between the number of chronic conditions, the number of prescriptions filled, the rates of unnecessary hospitalization, and average per capital health care spending (Partnership for Solutions, 2002)
|
From page 253... ...
Transfers among care settings are common. Twenty-three percent of hospitalized patients over the age of 65 are discharged to another institution, and 11.6 percent are discharged with home health care (Agency for Healthcare Research Quality, 1999)
|
From page 254... ...
These studies have shown that patients are often unprepared for their self-management role in the next care setting, receive conflicting advice regarding chronic illness management, are often unable to reach an appropriate health care practitioner who has access to their care plan when questions arise, have minimal input into their care plan, and are annoyed by having to repeatedly provide the same information to each new set of practitioners. Family caregivers voice feelings of frustration that they are often excluded from care planning meetings, despite their central role in the execution of this care plan.
|
From page 255... ...
. PERFORMANCE MEASUREMENT AS A POTENTIAL DRIVER FOR QUALITY IMPROVEMENT IN TRANSITIONAL CARE The underlying premise behind this report is that the absence of performance measurement for transitional care is one of the most significant barriers to quality improvement.
|
From page 256... ...
From this perspective, integrating transitional care into national performance measurement activities could have a profound impact as a primary driver of quality improvement. Fortunately, there are a number of points of leverage addressed by transitional care from which to build such an initiative.
|
From page 257... ...
An advisory meeting on transitional care performance measurement was held at CMS in August, 2004.2 The meeting included representation from CMS, National Quality Forum (NQF) , National Committee for Quality Assurance (NCQA)
|
From page 258... ...
7. Agree on the focus for quality improvement (i.e., structure, process, or outcome)
|
From page 259... ...
Illustrative examples of this approach are highlighted in an upcoming section entitled "Current Transitional Care Efforts Among Leading Quality Improvement Organizations." A fourth consideration examines the types of data sources needed for measurement. To date, data have been gathered through patient report, administrative data, chart review, and on-site survey.
|
From page 260... ...
For example, the Colorado Foundation for Medical Care (QIO serving Colorado and other mountain states) has initiated a quality improvement project that aims to enhance communication around skin integrity and pressure ulcers between hospitals and nursing homes in Denver.
|
From page 261... ...
Although the physical transfer of information across settings represents an important step towards quality improvement, even more important is how the available information is incorporated into a continuous care plan and used to improve health outcomes. Further, measurement efforts that focus on the quality of the "hand-off" across settings may lose sight of the fact that
|
From page 262... ...
unnecessary. Finally, to date the National Quality Forum has not approved any of these measures.
|
From page 263... ...
For example, Care Plan Oversight (CPT code 99374 for home health care) involves physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including phone calls)
|
From page 264... ...
Very few of these measures have been used in quality improvement initiatives and as a result, the accountable party remains undefined. There are few examples whereby these measures have been tested "head-to-head" to understand their strengths and limitations.
|
From page 265... ...
This item estimates the percentage of health plan members who had a follow-up visit after being discharged from an inpatient mental health stay for depression, schizophrenia, attention deficit disorder, and personality disorders (National Committee for Quality Assurance, 2004)
|
From page 266... ...
Funded by The Robert Wood Johnson Foundation and housed at America's Health Insurance Plans, the Care Management Workgroup (comprised of medical directors and operations leaders of leading health care delivery systems) recently completed a report aimed at educating health care delivery systems on evidence-based transitional care and best practices
|
From page 267... ...
Analogous to the care oversight codes allowed under Medicare, pediatricians believe there should be codes for generating the care plan, sharing the information with family and involved clinicians and also communicating with the schools. Documentation of these activities could be a performance measure.
|
From page 268... ...
. CHALLENGES TO APPLYING THESE MEASURES FOR THE PURPOSES OF QUALITY IMPROVEMENT, PAY FOR PERFORMANCE, AND PUBLIC REPORTING Challenges to implementing performance measurement for transitional care center around the misalignment of financial incentives, the unexplored accountability, the difficulty sorting out failed "hand-offs" from worsening illness, the limited utility of administrative data, and the lack of training
|
From page 269... ...
While performance measurement in general and payfor-performance in particular could positively influence the alignment of financial incentives, there will likely be significant resistance from the health care industry in defense of the status quo. There has been limited experience exploring what aspects of transitional care health plans, institutions, and clinicians can be held accountable.
|
From page 270... ...
RECOMMENDATIONS This final section attempts to synthesize the earlier sections towards the development of specific performance measurements recommendations for transitional care. Research and quality improvement efforts have predominantly focused on transitions out of institutional settings such as hospitals and skilled nursing facilities and accordingly, the recommendations reflect these advances.
|
From page 271... ...
Criteria for Good/Good Enough: · Congruent with six aims for quality improvement and rules for redesigning health care articulated in the IOM Chasm report · Congruent with the key domains identified in qualitative studies as important to patients and family caregivers (i.e., patient/caregiver preparation for self-care and what to expect in next setting, information transfer, medication reconciliation, follow-up appointments and testing) · Track record for use in "real-world" quality improvement projects · Formal psychometric testing has been performed · Items are in the public domain · Items are actionable at either the clinician level or at the system level · Items have been tested in more than one "hand-off" or setting · Items can be incorporated into existing performance measurement activities, where they exist · Scores have been shown to be associated with other meaningful processes or outcomes · Scores have been shown to discriminate among different providers 1a.
|
From page 272... ...
To date, CTM items are being used in at least four quality improvement projects, including one that focuses on pay for performance for transitional care. As noted earlier, the CTM developers have held a series of meetings with JCAHO leaders regarding a possible role for the CTM in assessing the quality of discharge planning as part of the Tracer Methodology initiative.
|
From page 273... ...
HCAHPS items have been used in public reporting as part of the CHCF initiative described above, but again, it is not clear if any transitional care specific quality improvement initiatives have been implemented as a result. It is also not known whether these items are associated with or predict rehospitalization.
|
From page 274... ...
If a vulnerable elder is discharged from hospital to home and survives at least 4 weeks after discharge, then he or she should have a follow-up visit or documented telephone contact within 6 weeks of discharge and the physician's medical record documentation should acknowledge the recent hospitalization. If a vulnerable elder is discharged from hospital to home or to a nursing home, then there should be a discharge summary in the outpatient physician or nursing home record within 6 weeks.
|
From page 275... ...
With the rapid proliferation of electronic health information systems, new strategies will be needed for how requisite information can be abstracted for the purpose of performance measurement. This will require exploring how to foster greater interoperability to those settings that traditionally have not had electronic health information systems such as nursing homes and home health agencies.
|
From page 276... ...
2004. Proposed Summary of Draft 8th Statement of Work for Quality Improvement Group.
|
From page 277... ...
2000. A geriatric hospitalist program for nursing home residents.
|
From page 278... ...
9.19.22. In Appropriateness of Minimum Nurse Staffing Ratios for Nursing Homes.
|
From page 279... ...
2003. Quality Indicators for Continuity and Coordination of Care in Vulnerable Elders.
|
From page 280... ...
Patients patients discharges Satisfaction PREPARED NA Patient Patient Hospitalized NA patients Referral Data 40 Chart System Home care All Inventory (RDI) referrals referrals Press Ganey 9 Patient Patient Patients in All multiple settings discharges (see section on settings)
|
From page 281... ...
Home care Yes Yes Proprietary Yes Hospital Yes/Noc unconfirmed Rehab SNFb Home care Yes Proprietary Yes Hospital Yes (continued on next page)
|
From page 282... ...
282 APPENDIX I TABLE I-5 continued No. Name of of Data Measure Measure Measure Items Source Perspective Population Sampling CAHPS Patients' 2 Patient Patient Children ?
|
From page 283... ...
APPENDIX I 283 Proprietary Prior Use In What Are Items Psychometric or Public in Quality Settings Actionable Testing? Domain?
|
From page 284... ...
If a vulnerable elder is discharged from hospital to home or to a nursing home, then there should be a discharge summary in the outpatient physician or nursing home record within 6 weeks. If a vulnerable elder is discharged from hospital to home or to a nursing home, and the transfer form or discharge summary indicates that a test result is pending, then the outpatient or nursing home record should include the test result within 6 weeks of hospital discharge.
|
From page 285... ...
Training given to you and your family about your care at home (inpatient rehabilitation) Degree to which you were included in the planning of your discharge (nursing home)
|
From page 286... ...
A complete list of the patient's medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner, or level of care within or outside the organization. CMS 7th SOW and JCAHO -- Heart Failure: Percent of Patients Discharged Home with Written Discharge Instructions or Educational Material (Centers for Medicare and Medicaid Services, 2002)
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.