Appendix I
Commissioned Paper

Transitional Care Performance Measurement

Eric A. Coleman

INTRODUCTION

Whether our goals are to improve quality, enhance patient-centered care, ensure patient safety, or implement cost containment practices, the time has come to focus our attention on performance measurement for transitional care. The absence of measurement in this area remains a significant barrier to achieving these goals. Lack of attention to transitional care is the result of multiple factors: accountability is poorly defined, financial incentives are not aligned, information systems are not well connected across settings, each setting requires the use of unique databases and documentation, and most practitioners have received minimal training for cross-site collaboration (Coleman, 2003; Coleman and Berenson, 2004; Coleman and Fox, 2004). Yet despite these potential barriers, transitional care is an essential and cross-cutting area of health care for persons with complex health care needs, including older adults, children with special health care needs, and disabled populations. 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.

Definitions

A recent position statement defines transitional care as a set of actions designed to ensure the coordination and continuity of health care as pa-



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Performance Measurement: Accelerating Improvement Appendix I Commissioned Paper Transitional Care Performance Measurement Eric A. Coleman INTRODUCTION Whether our goals are to improve quality, enhance patient-centered care, ensure patient safety, or implement cost containment practices, the time has come to focus our attention on performance measurement for transitional care. The absence of measurement in this area remains a significant barrier to achieving these goals. Lack of attention to transitional care is the result of multiple factors: accountability is poorly defined, financial incentives are not aligned, information systems are not well connected across settings, each setting requires the use of unique databases and documentation, and most practitioners have received minimal training for cross-site collaboration (Coleman, 2003; Coleman and Berenson, 2004; Coleman and Fox, 2004). Yet despite these potential barriers, transitional care is an essential and cross-cutting area of health care for persons with complex health care needs, including older adults, children with special health care needs, and disabled populations. 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. Definitions A recent position statement defines transitional care as a set of actions designed to ensure the coordination and continuity of health care as pa-

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Performance Measurement: Accelerating Improvement tients transfer between different locations or different levels of care within the same location. Representative locations include (but are not limited to) hospitals, subacute and postacute nursing facilities, the patient’s home, primary and specialty care offices, assisted living, and long-term care facilities. Ideally, transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patient’s goals, preferences, and clinical status. It should include logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition (Coleman and Boult, 2003). Transitional care is distinguished from discharge planning in that the former encompasses both the sending and the receiving aspects of the transfer. Transitional care is primarily concerned with the relatively brief time interval that begins with preparing a patient to leave one setting and be received in the next. Many transitions are unplanned, result from unanticipated medical problems, occur in “real time” during nights and on weekends, and happen so quickly that formal and informal support mechanisms cannot respond in a timely manner. While the focus of this background paper is on the “hand-offs” of care that occur as patients with complex care needs move across settings, it is important to acknowledge that transitional care shares key attributes with both coordination of care and continuity of care (Institute of Medicine, 2001, 2004). A comprehensive discussion of the latter two care domains is beyond the scope of this report. However, the intersection between transitional care, coordination of care, and continuity of care will be highlighted in this report. Transitional Care in Context Transitional care highlights a fundamental disconnect within the U.S. health care delivery system. The focus of transitional care is inherently patient-centered, attempting to ensure that the health care needs of patients with complex care are met irrespective of where care is delivered. 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. There are few mechanisms in place for coordinating care across settings, and often no single practitioner or team assumes responsibility during patients’ transitions. As was discussed during the December 1st 2004 Workshop, Dr. Mark Miller, Executive Director of MedPAC, acknowledged that organizing payment and quality setting by setting is not satisfactory. He expressed, however, that there exists a high level of interest in better coordination of these activities across settings.

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Performance Measurement: Accelerating Improvement It has become increasingly rare for a single physician or nurse care manager to take responsibility for coordinating care across settings during a care transition. Nationwide, practitioners are limiting the scope of their practice to a single setting such as the hospital, nursing home, or ambulatory clinic (Katz et al., 2000; Wachter and Goldman, 2002). Further, health care professionals frequently transfer patients to settings in which they have never practiced. They are often unfamiliar with the capacity of these settings for delivering care and may transfer patients to these settings inappropriately. As hospitals struggle with problems of overcapacity, they are frequently diverting patients to care settings where their personal physician does not practice and where the patient’s prior medical records are unavailable (Bazzoli et al., 2003; Brewster et al., 2001). Few health delivery systems currently have access to an electronic health record system, and even fewer have a system with connectivity to rehabilitation or skilled nursing facilities or home health care (ASTM International et al., 2003; Institute of Medicine, 2003; Kramer et al., 2004). Further, institutions and physicians assume minimal financial risk for ensuring safe and effective care transitions. Aside from capitation, most payment approaches do not penalize providers for inappropriate discharges or transfers. An Office of Inspector General report determined that in 1996 and 1997, 34,500 hospital patients were discharged and readmitted on the same day, with accompanying payments of nearly $226 million (U.S. DHHS, 2000). However, within Medicare’s statutory framework, Conditions of Participation explicitly include requirements concerning continuity of care and discharge planning for hospitals, home health agencies, rehabilitation and skilled nursing facilities. For hospitals, the Joint Committee on Accreditation of Healthcare Organizations (JCAHO) has deemed status from the Centers for Medicare and Medicaid Services (CMS) to provide oversight for these Conditions of Participation. In 2002, more than 90 percent of all hospitals nationwide received the highest score of 5/5 (i.e., “substantial compliance”) for these accreditations items. As will be discussed further in the next section, these findings are in sharp contrast to the growing evidence base that demonstrates there are serious quality problems in transitional care. Equally important, from a measurement standpoint, such high ratings for these items may indicate the need for revision. Our understanding of the health care utilization patterns and accompanying influence on health care expenditures for the population of persons with complex care needs is increasing. The Robert Wood Johnson Foundation-funded 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). Although

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Performance Measurement: Accelerating Improvement persons with 5 or more chronic conditions average 15 office visits and fill 50 prescriptions per year, they frequently do not receive adequate information regarding medication administration, illness management, and follow-up testing and procedures (Partnership for Solutions, 2002). Focusing on the Medicare beneficiary population, this poll revealed that beneficiaries with 2 or more chronic conditions see 7 different physicians per year, fill 20 prescriptions, and account for 95 percent of Medicare expenditures (Wolff et al., 2002). Within this subgroup, beneficiaries with 5 or more conditions account for two-thirds of Medicare spending. 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). An estimated 19 percent of patients discharged from a hospital to an SNF are readmitted to the hospital within 30 days (Kramer et al., 2000). One study tracked posthospital transitions for 30 days in a large, nationally representative sample of Medicare beneficiaries. Transitions in this study were defined as transfers to or from an acute hospital, skilled nursing or rehabilitation facility, or home with or without home health care. Overall, 46 unique care patterns were identified during this relatively brief 30-day time period. Sixty-one percent of care episodes resulted in one transition, 18 percent in two transitions, 9 percent in three transitions, 4 percent in four or more transitions, and 8 percent resulted in death (Coleman et al., 2004a). Finally, a discussion of the context within which transitional care occurs would not be complete without describing the factors that contribute to patients’ vulnerability. Not surprisingly, transitions in patients’ care settings parallel transitions in their physical health status. As such, these patients are not only adjusting to new settings but also to new or worsening health symptoms or changes in their ability to carry out daily functional tasks (Mor et al., 1989). Those patients in institutional settings often adapt to the environment by becoming dependent and complacent while their needs are being addressed; however, upon discharge to home, patients and family members are abruptly expected to assume a considerable self-management role in the recovery of their condition, with little support or preparation. The prevalence of transient or permanent cognitive impairment and limited health literacy among patients experiencing care transitions only exacerbates this challenge to preparing for self-care (Gazmararian et al., 1999; Kiely et al., 2003). Finally, family caregivers are both the first and last line of defense for ensuring safe and effective care transfers for these vulnerable patients. Their contributions in this area are vastly underestimated as they compensate for the many deficiencies of our current health care system. It is difficult to discuss family caregiving without discussing the challenges of coordinating care across settings. Conversely, it is nearly im-

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Performance Measurement: Accelerating Improvement possible to discuss the challenges of coordinating care across settings without recognizing the essential role of family caregivers.1 EVIDENCE FOR SERIOUS QUALITY PROBLEMS DURING CARE TRANSITIONS An expanding evidence base demonstrates that serious quality problems exist for patients undergoing transitions across sites of care. Qualitative studies performed in the United States as well as Canada, Europe, and Australia, have produced remarkably consistent results. 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. They are also dissatisfied with having to perform tasks that their health care practitioners have left undone (Coleman et al., 2002; Grimmer et al., 2000; Harrison and Verhoef, 2002; Levine, 1998; vom Eigen et al., 1999; Weaver et al., 1998). A recent report by the California Health Care Foundation (CHCF) reinforces these qualitative findings. CHCF surveyed over 36,000 patients to learn of their experiences during their recent stays in 200 California hospitals (approximately one-half of all hospitals in the state). Patients’ experience with transition to home was the lowest of all patient-rated hospital measures (CHCF, 2004). Quantitative studies have documented that patient safety is jeopardized due to high rates of medication errors and lack of appropriate follow-up care (Beers et al., 1992; Dudas et al., 2001; Forster et al., 2003; Moore et al., 2003). During care transitions, patients receive medications from different prescribers who rarely have access to patients’ comprehensive medication list (Partnership for Solutions, 2002). As such, no one clinician is ideally positioned to monitor the entire regimen and intervene to reduce discrepancies, duplications, or errors. Thus although much of the recent national attention on medication errors has been setting-specific, the lack of coordination between prescribers across settings may pose an even greater 1   At the time of the writing of this report, the National Family Caregiving Association has partnered with the University of Colorado Health Sciences Center to seek Congressional appropriations to commission an Institute of Medicine (IOM) report that would address the need to more formally support the role of family caregivers in general and in the context of coordination of care across settings in particular.

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Performance Measurement: Accelerating Improvement challenge. Forster and colleagues found that 19 percent of patients discharged from the hospital experienced an associated adverse event within 3 weeks (Forster et al., 2003); 66 percent of these were adverse drug events. Moore and colleagues examined three types of discontinuity among older patients transferred from the hospital: medication, test result follow-up, and initiation of a recommended work-up. They found that nearly 50 percent of hospitalized patients experienced at least one discontinuity and that patients who did not have a recommended work-up initiated were six times more likely to be re-hospitalized (Moore et al., 2003). In contrast to the studies led by Foster and Moore, which were conducted in tertiary academic health centers, researchers at the University of Colorado Health Sciences Center studied older patients receiving care from multiple community settings and found that 15 percent had at least one medication problem (Coleman et al., 2004b). Significant lapses in information transfer also threaten patient safety. Each time a patient’s medical record is recreated, it increases the chance for a medical error to occur. Further, inadequate information transfer potentially increases health care expenditures. Re-creation of essential information is inefficient and can lead to redundant ordering of laboratory tests, diagnostic imaging, and procedures. Studies by van Walraven and colleagues have documented not only failures in information transfer, but they have also documented that the information that is transferred is frequently incomplete and even inaccurate (van Walraven et al., 2002a,b). Leaders from the American Medical Directors Association have shown that despite requirements articulated by Medicare Conditions of Participation, skilled nursing facilities to not receive a discharge summary from the hospital approximately 28 percent of the time (Coleman et al., 2003). Each of the types of qualitative and quantitative problems described above conspire to increase rates of recidivism to high-intensity care settings when patients’ care needs are not met, increase the frequency of medical errors, and increase costs of health care (Beers et al., 1992; Boockvar et al., 2004; Coleman et al., 2004c; Moore et al., 2003; van Walraven et al., 2002a). In a national study examining 30-day post–hospital care patterns in a representative sample of Medicare beneficiaries, between 12 and 25 percent of all care patterns were categorized as complicated, requiring return to higher intensity care settings (Coleman et al., 2004a). 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. Lack of financial incentives and account-

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Performance Measurement: Accelerating Improvement ability make these “hand-offs” of care extremely vulnerable to medical errors, service duplication, and unnecessary utilization. And yet without processes in place to measure performance, the serious quality problems discussed in the prior section will remain undetected, and consequently, ignored. 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. These include national attention to the problem of patient safety in general and medication safety in particular, national efforts towards making the health care system more patient-centered (CMS, 2004; Hibbard et al., 2004; IOM, 2000, 2001), cost containment, and expansion of health information technology. Greater attention to transitional care could foster each of the efforts but before this can happen, performance measurement will be needed. In other words, performance measurement could drive improved quality, patient safety, cost containment, and development and dissemination of health information technology. Recent developments demonstrate that this position is achievable. JCAHO has identified medication reconciliation across settings as one of its top patient safety goals (CMS, 2004). In response, hospitalist physicians have begun to develop quality improvement initiatives and protocols for information transfer (discussed further in a subsequent section entitled “Current Transitional Care Efforts Among Leading Quality Improvement Organizations”). JCAHO has also recently implemented a new tracer methodology employed during on-site surveys designed to assess standards compliance by following a few, select active patients through the organization’s health care process in the same sequence experienced by patients. In so doing, surveyors may assess the relationships between disciplines and important functions during these care activities (JCAHO, 2004b). Criteria for selecting tracer conditions include: patients who have received complex services (often those close to discharge), patients who cross different programs (such as behavioral health and hospital), and patients whose care or condition relate to organizational systems (such as medication management or infection control). Although currently in the planning stages, there is some interest in expanding the tracer methodology across settings, such as from a JCAHO accredited hospital to a JCAHO accredited nursing home. In the realm of health information technology, national leaders in geriatric care coordination and electronic health information systems met with Dr. David Brailer who leads the Office of the National Coordinator for Health Information Technology with the Department of Health and Human Services. The discussion centered primarily around how to incorporate

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Performance Measurement: Accelerating Improvement information into electronic health information systems that was not only meaningful to patients with complex care needs, but also of use for capturing performance measurement as an essential step towards quality improvement. Another critical step that was discussed was to encourage interoperability of electronic health information systems across settings, including nursing homes and home health care agencies. 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), AARP, Associates in Process Improvement, National Family Caregivers Association, PeaceHealth, University of Colorado Health Sciences Center, and Commonwealth Fund. Overall, there was a high level of interest in advancing quality improvement in the area of transitional care in general and the utility of the University of Colorado Health Sciences Center’s Care Transitions Measure (CTM) in particular (the CTM is discussed in detail below in the section on Leading Performance Measures). Although the Advisory Committee acknowledged that the 8th Scope of Work for the nation’s Quality Improvement Organizations (QIOs) does not address this topic directly, there was discussion on how to best partner with QIOs to weave transitional care performance measurement into existing activities, such as advancement of health information technology and hospital and nursing home performance. At the recommendation of the Advisory Committee, researchers at the University of Colorado Health Sciences Center have initiated a process of collaboration with QIOs, including a “kick-off” WebEx presentation for which 46 QIO staff members attended, and direct participation in four QIO projects that directly pertain to transitional care. In general the QIOs seems motivated to move out of their setting-centric focus. Finally, performance measurement could be an important driver to increase demand for the growing number of evidence-based interventions that have been found to improve the quality of transitional care (Coleman et al., 2004c; Naylor et al., 1999; Rich et al., 1995; Stewart et al., 2000). In other words, once health care providers and delivery systems are asked to measure their performance, undoubtedly some will prove to have deficiencies. The fact that interventions have already been developed, tested, and implemented in clinical practice could facilitate advancement through the quality improvement cycle. 2   Dr. Eric Coleman from the University of Colorado convened and chaired this meeting that served to advise a performance measurement/quality improvement project supported by the Commonwealth Fund of New York.

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Performance Measurement: Accelerating Improvement Key Measurement Considerations The following section addresses key measurement considerations for pursuing a performance measurement agenda focused on transitional care (Box I-1). Some of these considerations are unique to the topic of transitional care while other considerations are applicable to most measurement efforts. A first consideration is to resist the temptation to oversimplify measurement in this area. To embrace transitional care is to embrace complexity. A “hemoglobin A1c equivalent” does not currently exist for transitional care, nor is it likely that a single summative measure available from administrative or laboratory data will be able to adequately capture the transitional care experience for patients with complex care needs. A second consideration is the perspective from which performance should be assessed. For example, should performance be measured from the standpoint of the patient, the sending care team, the receiving care team, or the broader health care system? The challenges faced when measuring performance in this area were raised earlier in this report. They include identifying who is accountable for care across settings, poorly aligned financial incentives, and the fact that few if any practitioners move across settings with the patient. Given these realities, no single approach to defining the perspective represents a “gold standard.” Some health care systems have chosen to define and measure care processes that are to take place at the time of transfer for both the sending and receiving care teams (Coleman and Fox, 2004). Others have reasoned that because patients and their family caregivers are often the only common thread weaving across disparate health care settings, they are uniquely positioned to re- BOX I-1 Key Measurement Considerations Resist the temptation to oversimplify measurement in this area. Choose the perspective from which performance should be assessed. Determine whether measurement should be a separate activity or integrated into a larger effort. Examine what type of data sources needed for measurement. Select the health care settings for which transitional care measures will apply. Decide whether all patients undergoing care transitions should be assessed or only those identified as high-risk. Agree on the focus for quality improvement (i.e., structure, process, or outcome). Explore whether there is a role for case-mix adjustment.

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Performance Measurement: Accelerating Improvement port on the care they have received (Coleman et al., 2004d; Grimmer and Moss, 2001; Hendriks et al., 2001). Finally, broader measures of health utilization that attempt to examine the problems that arise during care hand-offs from a more systems-oriented focus have also been explored (Coleman et al., 2004a). A third consideration concerns whether performance measurement in transitional care should be a separate dedicated activity or whether it should be integrated into a larger effort. As stated in the Introduction, transitional care is a cross-cutting area within health care and, as such, measurement in this area perhaps should not occur in isolation. Rather, to promote adoption, transitional care measurement may be best served by incorporating relevant items into existing measurement activities. 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. Both researchers and leading quality improvement organizations have raised concerns with each approach. For instance, do patients have the ability to evaluate their transition-related experiences at a time when their judgment may be compromised by acute illness? Can examination of administrative data or claims capture the patient’s experience? If processes of care are not documented in a patient’s record, is this because they were not done, they were not documented, or there was a failure in communication between the sending and receiving site that was necessary to prompt the care process? In other words, how can the receiving clinician be expected to document that a revision in a patient’s medication regimen occurred in a prior setting if that information was not transferred? Enhanced interoperability of electronic health information systems could potentially overcome some of these limitations. However, for the present time, if a reasonable immediate goal is to incorporate assessment of transitional care performance into existing efforts, then the types of data required will need to simply mirror these activities. A fifth consideration focuses on what health care settings should transitional care measures apply. To date, most measurement activity has focused on transfer out of the hospital. As was pointed out by Dr. Elliott Fisher during the December 1st 2004 Workshop, one problem with this approach is that it does not reward high-quality care that averts the hospitalization in the first place. Yet in order to promote broader quality improvement efforts, priority needs to be given to measures that can be employed across multiple settings. Initially, researchers from the University of Colorado Health Sciences Center embarked on the task of creating a series of “modu-

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Performance Measurement: Accelerating Improvement lar” measures for transitional care. As part of this effort, a measure would be constructed to assess transitional care from hospital to nursing home, nursing home to home health care, home health care to primary care, and so forth. The research team abandoned this approach as their experiences strongly suggested that there exists a core set of items that “transcend the transition” or are important irrespective of the transition in question. These items reflect the same domains that the qualitative studies cited earlier identified: patient preparation (both for what to expect and readiness for self-care), information transfer, medication management and/or reconciliation, and follow-up appointments and testing. A sixth consideration is whether to assess all patients undergoing care transitions or only those identified as high-risk for poor-quality or complicated care transitions. There are some conditions that traditionally lead to multiple transfers among care settings, such as acute stroke, congestive heart failure, and hip fracture (Coleman et al., 1999). Tools have been developed to identify patients at risk for complicated care transitions (Coleman et al., 2004a). JCAHO’s tracer methodology (described earlier) has included patients who undergo orthopedic procedures for joint replacement. As experience with measurement in this area has been limited, assessing all patients undergoing transitions may allow health care leaders the opportunity to gain a comprehensive view of the quality of transitional care that could better inform targeting for successive efforts. A seventh consideration examines the type of quality that is being measured, including structure, process, and outcome. To date, process measures represent the vast majority of efforts and relationships between care processes and outcomes are becoming increasingly salient (Coleman and Berenson, 2004; Coleman et al., 2004d). In discussions with adult and pediatric health care leaders, a number of structural items have also been put forth. 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. A number of different strategies have been employed but one approach in particular appears to stand out as being most effective—the opportunity for the hospital nurse and nursing home nurse to exchange information via a 5-minute telephone call. Thus despite efforts to create new paper forms or implement a common language for communication of a patient’s skin integrity, a structural modification in a nurse’s daily workflow that facilitates this person-to-person dialog may be worthy of assessment. Similarly, pediatric health care leaders conveyed another structural modification that could be assessed—creating time during business hours for the “back-office” staff to help children with special health care needs and their families obtain referrals, schedule appointments, commu-

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Performance Measurement: Accelerating Improvement TABLE I-5 Potential Measures of Care Transitions Name of Measure No. of Items Data Source Perspective Measure Population Measure Sampling PEP-C II/Picker 3 Patient Patient Hospitalized patients All discharges Care Transitions Measure (CTM) 3 Patient Patient Patients in transition (see section on settings) All transfers HCAHPS 2 Patient Patient Hospitalized patients All discharges ACOVE 3 Chart System Older adults All discharges Assessing (In)Patients Satisfaction 4 Patient Patient Hospitalized patients All discharges PREPARED NA Patient Patient Hospitalized patients NA Referral Data Inventory (RDI) 40 Chart System Home care referrals All referrals Press Ganey 9 Patient Patient Patients in multiple settings (see section on settings) All discharges NCQA Follow-Up After Hospitalization for Mental Illness 1 Admin or Chart System Hospitalized for mental illness Patients with depression, schizophrenia, attention deficit disorder, personality disorders

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Performance Measurement: Accelerating Improvement Psychometric Testing? Proprietary or Public Domain? Prior Use in Quality Improvement? In What Settings Used? Are Items Actionable by Clinicians? Yes (unconfirmed) Proprietary Yes Hospital Yes Yes Public Yes Hospital SNFa Home Clinic Yes Yes Public ? Hospital Yes/Nob Yes (unconfirmed) Public Yes Hospital Clinic Yes Yes Public ? Hospital Yes/Nob Yes Public NA Hospital ? Yes Public ? Home care Yes Yes Proprietary Yes unconfirmed Hospital Rehab SNFb Home care Yes/Noc Yes Proprietary Yes Hospital Yes

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Performance Measurement: Accelerating Improvement Name of Measure No. of Items Data Source Perspective Measure Population Measure Sampling CAHPS Patients’ Experiences w/Coordination of Their Child’s Care 2 Patient Patient Children with special care needs ? JCAHO Accreditation and Patient Safety Items 7 Site visit System Patientd Hospitalized adults Patients with predefined diagnoses are selected at random from certain wards CMS/JCAHO Heart Failure: % of Patients Discharged with Written Discharge Instructions 1 (6 sub-items) Chart System Hospitalized adults with congestive heart failure All discharges among this patient population aNA = Not available. Details regarding this measure were requested but no response provided. bSNF = skilled nursing facility. cSome items are actionable. The other items are not specific enough to be actionable by clinicians. dJCAHO has recently institued its “Tracer Methodology” that follows patients through a course of an inpatient illness and includes some patient interviews.

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Performance Measurement: Accelerating Improvement Psychometric Testing? Proprietary or Public Domain? Prior Use in Quality Improvement? In What Settings Used? Are Items Actionable by Clinicians? Yes Public Yes Clinic Yes/Nob Unknown Proprietary Yes Hospital Yes/Nob ? Public Yes Hospital Yes

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Performance Measurement: Accelerating Improvement Specific Wording of Items for Measures Included in the Table Patients’ Evaluation of Performance in California Survey (PEP-C-II) (California Health Care Foundation, 2004) Did someone on the hospital staff explain the purpose of the medicines you were to take at home in a way you could understand? Did they tell you what danger signals about your illness or operation to watch for after you went home? Did they tell you when you could resume your usual activities, such as when to go back to work or drive a car? Care Transitions Measure (Coleman, 2003) The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. When I left the hospital, I clearly understood the purpose for taking each of my medications. Hospital CAHPS (AHRQ, 2003) During your hospital stay, did hospital staff talk with you about whether you would have the help you needed when you left the hospital? During your hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital? The Assessing Care of Vulnerable Elders Measure (ACOVE)(Wenger and Young, 2003) If a vulnerable elder is discharged from a hospital to home and he or she received a new prescription medication or a change in medication before discharge, then the outpatient medical record should acknowledge the change within 6 weeks of discharge. 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. 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. If a vulnerable elder is under the outpatient care of >2 or more physicians, and 1 physician prescribed a new prescription medicine or change in medications, then subsequent medical record entries by the nonprescribing physician should acknowledge the medication change. Assessing (In)Patients’ Satisfaction (Hendriks et al., 2001) How satisfied are you about your exit interview upon discharge? How satisfied are you about the timing of your discharge from hospital? How satisfied are you about the information provided regarding further treatment (e.g., diet, working and resting hours, medication)?

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Performance Measurement: Accelerating Improvement How satisfied are you about the way information was passed on to your general practitioner, community care center, etc? PREPARED (Grimmer and Moss, 2001) Details about the measures were requested but no response was received Referral Data Inventory (RDI) (Anderson and Helms, 1995) 40 items divided into the following categories: background data (11 items); psychosocial data (9 items); medical data (10 items); nursing care data (10 items) Press Ganey (unpublished) Extent to which you felt ready to be discharged (hospital) Speed of discharge process after you were told you could go home (hospital) Instructions given about how to care for yourself at home (hospital) Help with arranging home care services (if needed) (hospital) How well the doctor discussed your discharge plans and postdischarge care (inpatient rehabilitation) How well the nurses instructed you about caring for yourself at home (including medication) (inpatient rehabilitation) Helpfulness of the social worker in assisting with your discharge plans and posthospital arrangements (inpatient rehabilitation) 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) NCQA Follow-Up After Hospitalization for Mental Illness (National Committee for Quality Assurance, 2004) Estimates the percentage of health plan members who had a follow-up visit after being discharged from an inpatient mental health stay. The measure includes hospitalizations for depression, schizophrenia, attention deficit disorder, and personality disorders. CAHPS Patients’ Experiences with Coordination of Their Child’s Care (CAHPS, 2004) In the last 12 months, did you get the help you needed from your child’s doctors or other health care providers in contacting your child’s school or daycare? In the last 12 months, did anyone from your child’s health plan, doctor’s office or clinic help coordinate your child’s care among these different providers or services? JCAHO Accreditation and Patient Safety Items (JCAHO) (Joint Commission on Accreditation of Healthcare Organizations, 2001, 2004a) PF.3.9 Discharge instructions are given to the patient and those responsible for providing continuing care. CC.3.1 The hospital provides for coordination of care and services among health professionals and settings. CC.4 Referral, transfer, discontinuation of services, or discharge of a patient to other levels of care, health professionals, or settings is based on the patient’s assessed needs and each hospital’s capability to provide needed care and services.

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Performance Measurement: Accelerating Improvement CC.4.1 The follow-up process provides for continuing care to meet the patient’s needs. CC.4.1.1 The patient is informed in a timely manner of the need for planning for discharge or transfer to another organization or level of care. CC.5 Appropriate information related to the care and services provided is exchanged when a patient is accepted, referred, transferred, discontinued service, or discharged to receive further care or services. CC.3 The hospital provides for continuity over time among the care and services provided to a patient. (Patient Safety Goal) Develop a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list. (Patient Safety Goal) 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) Heart failure patients with documentation that they or their caregivers were given written discharge instructions or other educational materials addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen.