This document discusses evaluating improvements in care transitions between healthcare settings. It provides an overview of common issues during care transitions like medication errors and lack of communication. The document then proposes evaluating the transition of patients from nursing homes to hospitals and back using a framework involving structure, process, and outcome measures. Key parts of the evaluation are identifying areas to measure like information transfer, developing an evaluation matrix, assessing current performance over time, and ensuring proper IRB review.

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!