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Evaluating Transitions of Care Processes
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Evaluating Transitions of Care Processes

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  • Transition of care is the movement of patients from one health care practitioner or setting to another as their condition and care needs change and it necessarily occurs at multiple levels. It occurs 1) within settings, such as primary care and specialty care in the context of care in the community, 2) between settings, such as someone who moves from the hospital to the rehabilitation facility, and it occurs 3) across health states, such as from receiving care in the home to needing care in assisted living.
  • There are a number a factors we can identify that highlight care transition inadequacies. Some of these we see daily in our practices, some of them we may only hear about by chance (e.g., patient satisfaction survey, newly published primary literature about these problems), and some we see in the press (e.g., nursing facility sued due to poor transition from hospital that possibly resulted in death).
  • *Discrepancy defined as error between admission medication orders and patient interview of medication history. BACKGROUND: Prior studies suggest that unintended medication discrepancies that represent errors are common at the time of hospital admission. These errors are particularly worthy of attention because they are not likely to be detected by computerized physician order entry systems. METHODS: We prospectively studied patients reporting the use of at least 4 regular prescription medications who were admitted to general internal medicine clinical teaching units. The primary outcome was unintended discrepancies (errors) between the physicians' admission medication orders and a comprehensive medication history obtained through interview. We also evaluated the potential seriousness of these discrepancies. All discrepancies were reviewed with the medical team to determine if they were intentional or unintentional. All unintended discrepancies were rated for their potential to cause patient harm. RESULTS: After screening 523 admissions, 151 patients were enrolled based on the inclusion criteria. Eighty-one patients (53.6%; 95% confidence interval, 45.7%-61.6%) had at least 1 unintended discrepancy. The most common error (46.4%) was omission of a regularly used medication. Most (61.4%) of the discrepancies were judged to have no potential to cause serious harm. However, 38.6% of the discrepancies had the potential to cause moderate to severe discomfort or clinical deterioration. CONCLUSIONS: Medication errors at the time of hospital admission are common, and some have the potential to cause harm. Better methods of ensuring an accurate medication history at the time of hospital admission are needed.
  • *Most common discrepancy is omission of pre-admit medication. BACKGROUND: In the hospital setting, postoperative admission is a key vulnerable moment when patients are at increased risk of medication discrepancies. This study measures the reduction of medication discrepancies associated with a combined intervention of structured pharmacist medication history interviews with assessments in a surgical preadmission clinic and a postoperative medication order form. METHODS: In the Surgical Pharmacist in Preadmission Clinic Evaluation (SPPACE) study, patients who had a preadmission clinic appointment before undergoing surgical procedures were eligible for inclusion. Patients were excluded if they were scheduled for discharge the same day as their surgery. Eligible patients were randomly assigned to the intervention arm (structured pharmacist medication history interview with assessment and generation of a postoperative medication order form) or to the standard care arm (nurse-conducted medication histories and surgeon-generated medication orders). The primary end point was the number of patients with at least 1 postoperative medication discrepancy related to home medications. RESULTS: Between April 19, 2005, and June 3, 2005, a total of 464 patients were enrolled in the study, of which 227 and 237 patients were randomized to the intervention and standard care arms, respectively. In the intervention arm, 41 (20.3%) of 202 patients had at least 1 postoperative medication discrepancy related to home medications, compared with 86 (40.2%) of 214 patients in the standard care arm (P<.001). In the intervention arm, 26 (12.9%) of 202 patients had at least 1 postoperative medication discrepancy with the potential to cause possible or probable harm, compared with 64 (29.9%) of 214 patients in the standard care arm (P<.001). These were mostly omissions of reordering home medications. CONCLUSION: A combined intervention of pharmacist medication assessments and a postoperative medication order form can reduce postoperative medication discrepancies related to home medications.
  • *Work up error occurred if an outpatient test or procedure suggested or scheduled by the inpatient provider was not adequately followed up by the outpatient provider (e.g., colonoscopy for positive fecal occult blood test scheduled at discharge but not documented in outpatient chart). OBJECTIVE: To determine the prevalence of medical errors related to the discontinuity of care from an inpatient to an outpatient setting, and to determine if there is an association between these medical errors and adverse outcomes. PATIENTS: Eighty-six patients who had been hospitalized on the medicine service at a large academic medical center and who were subsequently seen by their primary care physicians at the affiliated outpatient practice within 2 months after discharge. DESIGN: Each patient's inpatient and outpatient medical record was reviewed for the presence of 3 types of errors related to the discontinuity of care from the inpatient to the outpatient setting: medication continuity errors, test follow-up errors, and work-up errors. MEASUREMENTS: Rehospitalizations within 3 months after the initial postdischarge outpatient primary care visit. MAIN RESULTS: Forty-nine percent of patients experienced at least 1 medical error. Patients with a work-up error were 6.2 times (95%confidence interval [95% CI], 1.3 to 30.3) more likely to be rehospitalized within 3 months after the first outpatient visit. We did not find a statistically significant association between medication continuity errors (odds ratio [OR], 2.5; 95%CI, 0.7 to 8.8) and test follow-up errors (OR, 2.4; 95%CI, 0.3 to 17.1) with rehospitalizations. CONCLUSION: We conclude that the prevalence of medical errors related to the discontinuity of care from the inpatient to the outpatient setting is high and may be associated with an increased risk of rehospitalization. Reference: Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to disontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med 2003;18:646-51.
  • Examples: Discontinue metoprolol – blood pressure rises to 208/108 mmHg; Discontinue insulin – blood glucose rises to >500 mg/dL. BACKGROUND: Care transitions are commonplace for ill older adults, but no studies to our knowledge have examined the occurrence of iatrogenic harm from medication changes during patient transfer. OBJECTIVES: To identify medication changes during transfer between hospital and nursing home and adverse drug events (ADEs) caused by these changes. METHODS: Participants were residents of 4 nursing homes in the New York City metropolitan area admitted to 2 academic hospitals. Nursing home and hospital medical records were reviewed to identify changes in medication regimens between sites. Medications were matched and compared regarding dosage, route, and frequency of administration. Two physician investigators used structured implicit review to identify ADEs attributable to transfer-related medication changes. RESULTS: During a total of 122 admissions, the mean numbers of medications altered during transfer from nursing home to hospital and hospital to nursing home were 3.1 and 1.4, respectively (P<.001 for comparison). Most changes in drug use were discontinuations, followed by dose changes and class substitutions. Of 71 bidirectional transfers that were reviewed by 2 physician investigators, ADEs attributable to medication changes occurred during 14 (20%). The overall risk of ADE per drug alteration (n = 320) was 4.4% (95% confidence interval, 2.5%-7.4%). Although most medication changes (8/14) implicated in causing ADEs occurred in the hospital, most ADEs (12/14) occurred in the nursing home after nursing home readmission. CONCLUSIONS: Medication changes are common during transfer between hospital and nursing home and are a cause of ADEs. Research is needed on interinstitutional patient care and systems interventions designed to prevent ADEs. Reference: Boockvar K, Fishman E, Kyriacou CK et al. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Arch Intern Med 2004;164:545-50.
  • 9 th scope of work

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  • 1. Evaluating Improvement in Transitions of Care Processes H. Edward Davidson, PharmD, MPH, FASCP Assistant Professor Eastern Virginia Medical School Partner, Insight Therapeutics & Cheri Lattimer, RN, BSN Executive Director Case Management Society of America American College of Healthcare Executives
  • 2. Learning Objectives
    • Learn how effective transitions of care strategies can improve quality of care
    • Analyze your organizations care transitions strategies and measure your degree of success
    American College of Healthcare Executives
  • 3. DEFINING TRANSITIONS OF CARE AND ITS IMPACT American College of Healthcare Executives
  • 4.
    • The movement of patients from one health care practitioner or setting to another as their condition and care needs change
    • Occurs at multiple levels
      • Within Settings
        • Primary care  Specialty care
        • ICU  Ward
      • Between Settings
        • Hospital  Sub-acute facility
        • Ambulatory clinic  Senior center
        • Hospital  Home
      • Across health states
        • Curative care  Palliative care/Hospice
        • Personal residence  Assisted living
    What is “Transitions of Care” (c) Eric A. Coleman, MD, MPH American College of Healthcare Executives
  • 5. Transition Issues Dramatically Impact Patient Care Patient ER ICU In-Patient Patient
    • OUTPATIENT:
      • Home
      • PCP
      • Specialty
      • Pharmacy
      • Case Mgr.
      • Care Giver
    SNF ALF American College of Healthcare Executives
  • 6. Transition Issues Dramatically Impact Patient Care Patient ER ICU In-Patient Patient
    • OUTPATIENT:
      • Home
      • PCP
      • Specialty
      • Pharmacy
      • Case Mgr.
      • Care Giver
    SNF ALF American College of Healthcare Executives NO Medication Reconciliation NO Personal Medicine List NO Coordinated Care Plan NO Discharge Care Plan NO Care Plan NO Medication Reconciliation NO Personal Medicine List NO Care Plan NO Medication Reconciliation NO Personal Medicine List
  • 7. Problems That Illustrate Inadequacies of Care Transitions (c) Eric A. Coleman, MD, MPH
    • Medication errors
    • Increased health care utilization
    • Inefficient/duplicative care
    • Inadequate patient/caregiver preparation
    • Inadequate follow-up care
    • Dissatisfaction
    • Litigation/Bad publicity
    American College of Healthcare Executives
  • 8.
    • System level barriers
    • Practitioner level barriers
    • Patient level barriers
    Barriers to Care Coordination American College of Healthcare Executives
  • 9. Breaking the Barriers Requires Communication American College of Healthcare Executives
  • 10. To Date We Have Not Had Consistent Accepted Transition Tools
    • Medication Reconciliation Elements
    • Comprehensive Care Plan
    • Patient & Caregiver Tools & Resources
    • Health or Clinical Status
    • Discharge Summary
    • Consistent Performance Measures That Apply to All Health Care Settings
    • Accountability for Sending & Receiving Information
    American College of Healthcare Executives
  • 11. Identifying Accountability Patient ER ICU In-Patient Patient
    • OUTPATIENT:
      • Home
      • PCP
      • Specialty
      • Pharmacy
      • Case Mgr.
      • Care Giver
    SNF ALF American College of Healthcare Executives ED Case Mgr Hospital Case Mgr Managed Care Case Mgr Continuum Case Mgrs
  • 12.
    • CMS 9 th SOW supports Care Coordination
      • Care Pathways
    • 2009 TJC Patient Safety Standard #8 enhanced Medication Reconciliation to include patient and caregiver involvement and transition
      • Documentation of process
    • NQF developing Performance Measures for Care Coordination
      • Call for Best Practices December 2008
      • Measures Development in 2009
    • URAC incorporating TOC principals in revised CM Standards
    • AMA – PCPI Transitions of Care
      • ACP/SHM/ABIM Foundation/PCPI will develop jointly practitioner-level performance measures for transitions of care
    Care Coordination & Transitions of Care American College of Healthcare Executives
  • 13. A National Effort to Address Transitions of Care Concerns American College of Healthcare Executives NTOCC is Co-Chaired by CMSA in Partnership with sanofi aventis
  • 14. 2008 Advisory Task Force
    • These groups represent over 200,000 health care professionals, 11,000 employers and 30,000,000 consumers throughout the United States.
    American College of Healthcare Executives
  • 15. Tools & Resources of NTOCC
    • Medication reconciliation Data Elements
    • Elements of Excellence Transitions of Care Check List
    • My Medicine List
    • Taking Care Of Healthcare
    • Improving Transitions of Care – The Vision of the National Transitions of Care Coalition
    • Improving on Transitions of Care – How to Implement and Evaluate a Plan
    American College of Healthcare Executives
  • 16. So How Do We Implement and Evaluate Transitions of Care Tools and Report on Improvement? American College of Healthcare Executives
  • 17. Evaluating Improvement in Transitions of Care Processes H. Edward Davidson, PharmD, MPH, FASCP Assistant Professor Eastern Virginia Medical School Partner, Insight Therapeutics American College of Healthcare Executives
  • 18. Hospital Admission
    • On hospital admission, more than 50% of patients have at least one medication discrepancy*
      • Approximately 40% of those have potential to cause harm
      • Most common discrepancy was omission of a regularly used medication
    American College of Healthcare Executives Cornish PL et al. Arch Intern Med 2005;165:424-9. *Discrepancy defined as error between admission medication orders and patient interview of medication history .
  • 19. Hospital Discharge
    • On discharge from the hospital, 30% of patients have at least one medication discrepancy* with the potential to cause possible or probable harm
    American College of Healthcare Executives Kwan Y et al. Arch Intern Med 2007;167:1034-40. *Most common discrepancy is omission of pre-admit medication.
  • 20. Hospital to Home
    • 40% of patients experienced at least 1 medical error
      • Those with a “work-up” error* were 6 times more likely to be rehospitalized within 3 months
    American College of Healthcare Executives Moore C et al. J Gen Intern Med 2003;18:646-51. *Work-up error occurred if an outpatient test or procedure suggested or scheduled by the inpatient provider was not adequately followed up by the outpatient provider (e.g., colonoscopy for positive fecal occult blood test scheduled at discharge but not documented in outpatient chart).
  • 21. Hospital to Nursing Home
    • Transfers and Adverse Events Adverse drug events (ADEs) attributable to medication changes occurred in 20% of bi-directional transfers
      • 50% of ADEs were caused by discontinuation of medications during hospital stay
    American College of Healthcare Executives Boockvar K et al. Arch Intern Med 2004;164:545-50.
  • 22. OIG Report – June ‘07
    • Consecutive Medicare stays involving inpatient and skilled nursing facilities in CY 2004
    • Key findings …
      • 35% of consecutive stays were associated with quality-of-care problems and/or fragmentation of services
      • 11% of individual stays within consecutive stay sequences involved problems with quality-of-care, admission, treatments or discharges
    American College of Healthcare Executives DHHS; OIG, June 2007; OEI-07-05-00340
  • 23. Evaluation Scenario
    • The bidirectional transfer of individuals from the nursing facility to the hospital/ED
    • Justification:
      • This scenario involves vulnerable elders
      • Has been the recent subject of scrutiny by OIG (consecutive Medicare stays)
      • Research has documented significant problems with this process
    American College of Healthcare Executives
  • 24. Why Evaluation?
    • Evaluation is the conscious reflection on what we do, with the aim of discovering:
      • Opportunities to improve practice (e.g., flaws in systems or processes)
      • Whether or not we have achieved the outcomes that we set out to achieve for patients; and/or whether key areas within our services are performing as expected
      • Whether or not an improvement has been made as a result of a quality improvement activity (e.g., a project or new process)
    American College of Healthcare Executives
  • 25. Evaluation Research
    • More rigorous than basic QI methods
    • Involves developing an evaluable model
      • A collective effort of all stakeholders
    • Use of a measurement chart to identify variables
    • Usually involves assessing baseline performance and comparing to a post-intervention period
    American College of Healthcare Executives
  • 26. Development of Model
    • Focus group meetings with:
      • Geriatricians/SNFists
      • SNF administrator
      • SNF admissions coordinator
      • Hospital discharge planners/social workers
    • Project planning meeting with:
      • Medicare QIO (Quality Partners – RI)
    American College of Healthcare Executives
  • 27. Transitions of Care Measures
    • Patients: all or selected groups
    • Applicability to health care settings/providers
    • Types of measures (structure, process, outcome, experience, effectiveness)
    • Focus of measures (perspective/experience of patients, providers)
    • Feasibility of data sources/data collection
    • Unit of measurement (individual/system)
    American College of Healthcare Executives Source: www.ntocc.org
  • 28. Key Elements of Framework
    • Structure
      • Accountable provider at all points
      • Tool for plan of care
      • Health information technology system
    • Process
      • Care team processes
      • Information transfer between providers/settings
      • Patient/family education and engagement
    American College of Healthcare Executives Source: www.ntocc.org
  • 29. Key Elements (cont.)
    • Outcomes
      • Patient/family experience and satisfaction
      • Provider experience and satisfaction
      • Health care utilization and costs
      • Health outcomes
    American College of Healthcare Executives Source: www.ntocc.org
  • 30. Environmental Scan For Measures
    • Joint Commission (National Patient Safety Goals)
    • National Quality Forum
    • Institute for Healthcare Information
    • ACOVE (Rand)
    • CMS
    • AHRQ
    American College of Healthcare Executives
  • 31. Identify Process Nodes
    • Case study: In a nursing home to hospital bi-directional transfer, you may consider that there are six exchanges
      • Exchange 1: Preparation in nursing home to transfer patient to hospital (nursing home handover)
      • Exchange 2: EMS/Ambulance transport
      • Exchange 3: Hospital receipt of patient
      • Exchange 4: Preparation in hospital to transfer patient back to nursing home (hospital handover)
      • Exchange 5: EMS/Ambulance transport
      • Exchange 6: Nursing home receipt of patient
    American College of Healthcare Executives
  • 32. American College of Healthcare Executives Live.gnome.org/dia
  • 33. Determine Evaluation Questions
    • Exchange 1
      • Evaluation Question 1: Is the appropriate information being communicated to the ED/hospital by nursing home staff?
      • Evaluation Question 2: Is there documentation in the nursing home medical record of communication with the primary care physician about the ED/hospital transfer?
      • Evaluation Question 3: Is there documentation in the nursing home medical record of communication with family/caregiver about transfer of the resident?
    American College of Healthcare Executives
  • 34. Develop Evaluation Matrix American College of Healthcare Executives
  • 35. American College of Healthcare Executives
  • 36. Assess Your Current Performance American College of Healthcare Executives
  • 37. Sample Trend Chart American College of Healthcare Executives minimum allowed original intervention modified intervention Original intervention Modified intervention Modified intervention
  • 38. IRB Review
    • All research that uses
      • Human subjects
      • Tissues/specimens from humans
      • Data/records from human subjects
    • Quality assurance, quality improvement, and program evaluations have the potential to involve human subjects and therefore are subject to IRB oversight
    American College of Healthcare Executives
  • 39. Research versus QI
    • 45 CFR 46.102: "Research means a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge."
    • 45 CFR 45.101(b)(4) (exempt from review): "Research involving the collection or study of existing data, documents, records, pathological specimens, or diagnostic specimens, if these sources are publicly available or if the information is recorded by the investigator in such a manner that subjects cannot be identified, directly or through identifiers linked to the subjects."
    American College of Healthcare Executives
  • 40. Rigor in QI Methods
    • “ The methods of evaluating change and improvement strategies are not well described. The general principle under-lying the choice of evaluative design is, however, simple—those conducting such evaluations should use the most robust design possible to minimize bias and maximize generalizability.”
    • Eccles M, et al. Qual Saf Health Care 2003;12:47-52.
    American College of Healthcare Executives
  • 41. Rigor in QI Methods
    • “ Improving the rigor of the quality improvement literature will build a stronger foundation and more convincing justification for the study and practice of quality improvement in health care.”
    • Speroff T, O’Connor GT. Qual Manag Health Care 2004;13:17-32.
    American College of Healthcare Executives
  • 42. American College of Healthcare Executives Questions & Answers Thank You!