National Academies Press: OpenBook

Performance Measurement: Accelerating Improvement (2006)

Chapter: Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman

« Previous: Appendix H Commissioned Paper: Efficiency/Value-Based Measures for Services, Defined Populations, Acute Episodes, and Chronic Conditions--Kyle L. Grazier
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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-

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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.

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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-

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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.

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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-

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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.

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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

  1. Resist the temptation to oversimplify measurement in this area.

  2. Choose the perspective from which performance should be assessed.

  3. Determine whether measurement should be a separate activity or integrated into a larger effort.

  4. Examine what type of data sources needed for measurement.

  5. Select the health care settings for which transitional care measures will apply.

  6. Decide whether all patients undergoing care transitions should be assessed or only those identified as high-risk.

  7. Agree on the focus for quality improvement (i.e., structure, process, or outcome).

  8. Explore whether there is a role for case-mix adjustment.

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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-

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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-

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

nicate with teachers and nurses at school and arrange for durable medical equipment.

A final consideration is case-mix adjustment, an important area with particular relevance to potential pay-for-performance initiatives. As this topic has been central to larger discussion of the Subcommittee, this section will concentrate on its relevance to assessing transitional care. As was discussed at the December 1st 2004 Workshop, process of care measures may not require formal case-mix adjustment techniques. As noted, the majority of transitional care measures assess processes of care. As such, case-mix adjustment has not served as a primary focus in this area. Hospital Consumer Assessment of Health Providers and Systems (HCAHPS) testing has demonstrated that the following three items are most critical for risk adjustment for the entire 25-item measure (i.e., not specific to the two discharge to home items that are detailed in the next section): age, education, and self-rated health status. Key case-mix adjustment variables have been identified for examining at recidivism, such as return to the hospital or emergency department after a transfer to a lower-intensity care setting (Coleman et al., 2004a).

LEADING PERFORMANCE MEASURES SETS ASSESSING QUALITY OF CARE DURING TRANSITIONS

Performance measures were identified through a comprehensive review of the medical literature, discussions with leaders within quality improvement organizations, discussions with academic experts, and searches of the Internet (primarily focused on the Web sites of quality improvement entities and supplemented with leading search engines). Identified measures are summarized in the table. If written materials or articles did not provide the complete requisite information to complete the table, attempts were made to contact the primary author. In some cases, the author chose not to respond.

Overall, there has been a recent proliferation of measures in this area. Initially, most attempts at quality measurement focused on post-hospitalization recidivism (either return to the hospital or to the emergency department). Now there is an expanding array of patient-centered measures and process of care measures that show promise for implementation in performance measurement initiatives. However, a number of caveats remain. There is growing interest in examining completeness and accuracy of information transfer across disparate care settings. 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

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

in some cases, high-quality care might obviate the need for a transition altogether. For example, having a patient remain in the hospital for an additional 1–2 days to receive rehabilitation before going home may make a transfer to a skilled nursing facility (and its accompanying risks for medical errors and iatrogenesis) unnecessary. Finally, to date the National Quality Forum has not approved any of these measures. However, a steering committee is being convened with a focus on care coordination for hospital and ambulatory care.

Performance measures focused on transitional care can be categorized into four general types or “buckets” including process of care measures, patient-reported measures of their experiences during transitions, outcomes of care, and accreditation measures. These measures reflect many of the key domains identified in the qualitative studies reviewed earlier, namely patient/caregiver preparation for self-care, information transfer, medication reconciliation, follow-up testing, or appointments with primary care or specialty clinicians.

The first bucket includes process of care or task-oriented measures. Representative measures include the Assessing Care of Vulnerable Elders (ACOVE) developed by RAND and UCLA and funded by Pfizer and the Anderson/Helms Referral Data Inventory (RDI). The ACOVE items examine whether certain tasks around communication across settings were achieved (Wenger and Young, 2003). The RDI was initially designed to assess the completeness of home health care referrals but has since been expanded to include other care settings (Anderson and Helms, 1995). A summative score is generated to reflect the completeness (but not the accuracy) of information transfer. Medication reconciliation is increasingly recognized as an important activity for patient safety by organizations such as the Institute for Healthcare Improvement (2004) and JCAHO (discussed further below). Within this process, pre- and posttransition care regimens are reconciled to reduce redundancy and prescribing errors.

The second bucket includes patient-reported measures of care experiences during care transitions. Representative measures include the HCAHPS developed by CMS and the Agency for Healthcare Research and Quality (AHRQ), the Patients’ Evaluation of Performance in California (PEP-C-II) and the CTM. HCAHPS was designed to serve as a voluntary measure of hospital performances, ideally adopted across the country (Agency for Healthcare Research and Quality, 2003). As such it primarily focuses on the care delivered during the hospital stay but also includes two items that reflect the discharge experience. The PEP-C-II incorporates items from the NRC—Picker group and has been used for public reporting in a collaborative effort between the CHCF and the California Institute for Health System Performance (CHCF, 2004). Similar to HCAHPS, this measure primarily focuses on the overall hospital experience but includes select items on the

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

transition to home. Researchers from the University of Colorado Health Sciences Center developed the CTM with an explicit and unique focus on the care transition experience (Coleman et al., 2004d). The CTM can be administered either as a 15-item and a 3-item (subset) measure, both of which have been shown to discriminate among hospitals and predict rehospitalization or return to the emergency department.

The focus of the third bucket is on outcomes, usually in the form of utilization of or recidivism to high-intensity health care services such as the hospital or emergency department. To date, this strategy has been the least developed. One approach, developed in the Medicare Current Beneficiary Survey, defines complicated care transitions as an interruption in the movement from higher intensity care settings (where there is presumably greater functional dependency and medical instability) to lower intensity care settings (Coleman et al., 2004a).

The fourth bucket includes accreditation measures, such as those used by JCAHO. The relevant JCAHO activities that pertain to transitional care are discussed in greater detail in the following section.

There are other potential approaches to assessing quality in this area that either do not fit into one of the buckets above or have not yet been attempted, for example, the completion or updating of an adult patient’s Personal Health Record (ASTM International et al., 2003) or information to support a child’s Medical Home within pediatric care (American Academy of Pediatrics, 2003). Inclusion of a completed Physician Orders for Life-Sustaining Treatment (Oregon Health and Science University, 1996) in the transfer information that accompanies a patient across settings could be converted into a measurement activity. Areas addressed may include: resuscitation, medical interventions, antibiotic usage, artificially administered fluids, and nutrition. Finally, a number of measures have been developed to assess the transition from pediatric to adult medical providers among teenagers (Reiss and Gibson, 2002).

CMS currently reimburses clinicians for a number of care coordination and care oversight activities that, if modified, could serve as a template for more formal performance measurement for transitional care. 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) for purposes of assessment or care decisions with health care professionals, family members, surrogate decision makers, and/or key caregivers involved in patient’s care, integration of new information into the medical treatment plan, and/or adjustment of medical therapy within a calendar month. In addition, Discharge Day Management (CPT code 99238 if <30 minutes or 99239 if >30 minutes) includes final examination, discussion of hospital stay, instructions for con-

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

tinuing care, and preparation of discharge records. Further strengthening of these codes to ensure greater accountability, foster more effective communication, and encourage more overt collaboration with family caregivers, combined with routine auditing, could represent important step towards financially rewarding high-quality transitional care.

In summary, the table illustrates the wide array of potential approaches that could be used for the purpose of transitional care performance measurement. Although great strides have been made in the area of transitional care performance measurement, collectively these measures stand to improve in a number of key areas. Each of the measures presented have relatively limited experience in testing in diverse populations. Most self-reported measures have not been formally tested in patient populations with transient or permanent cognitive impairment and as a consequence, do not have established protocol for when a proxy respondent is needed. 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. While measures may have been evaluated based on psychometric characteristics, the majority of measures have not been tested in “real-world” settings to determine whether scores are associated with positive or negative outcomes nor have the developers shown whether scores discriminate among different health care institutions. Finally, despite their integral role in facilitating safe and effective care transitions, the “voice” of family caregivers is not well represented among existing measures.

CURRENT TRANSITIONAL CARE EFFORTS AMONG LEADING QUALITY IMPROVEMENT ORGANIZATIONS

The NQF has initiated (January 2005) a new steering committee on coordination of care within and out of the hospital. As mentioned earlier, NQF has not approved any measures in this area; however, a call for measures has been issued with a due date of mid-January 2005. Also previously mentioned was NQF’s participation in the transitional care performance measurement meeting held at CMS in August 2004, during which there was considerable interest expressed for the University of Colorado Health Sciences Center’s CTM. CMS has held a series of listening sessions on the 39 NQF consensus standards for hospital care and care coordination was identified as a priority area among stakeholders. NQF has endorsed set of safe practices that recommends health care institutions should “ensure that care information, especially changes in orders and new diagnostic information, is transmitted in a timely and clearly understandable form to all of the

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

patient’s current health care providers who need that information to provide care.” NQF is in the process of exploring nursing care sensitive measures that may include items pertinent to transitional care.

The Leapfrog Group Hospital Patient Safety Survey incorporates the NQF-endorsed safe practices described above and provides a series of steps, based on awareness, accountability, ability, and actions to address the problem. This guide sets the stage for performance measurement to be developed and implemented by each participating individual hospital but does not offer specific measurement tools or items.

The experiences of the CHCF have been described earlier. CHCF surveyed over 200 hospitals using PEP-C-II and HCAHPS items for the purpose of public reporting. Hospital-level performance can be identified on their Web site.

Due to constraints in how performance data are obtained, NCQA has not developed specific measures in the area of transitional care in general. However, they have implemented a measure that examines follow-up after hospitalization for mental illness. 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). The measure looks at both 7-day and 30-day follow-up rates. CMS has asked NCQA to assemble an advisory group3 related to the “Doctor Office Quality-Information Technology” (DOQ-IT) project (Centers for Medicare and Medicaid Services, 2004). This pilot project, mandated by the Medicare Modernization Act, is aimed at paying for performance specifically related to physician office practices that implement changes in their use of information technology. It is conceivable that this new technology could be designed in such a way to facilitate information transfer and coordination across settings.

Bridges to Excellence has three programs under way: Physician Office Link, Diabetes Care Link, and Cardiac Care Link. Perhaps most relevant to transitional care, the Physician Office Link enables physician office sites to qualify for bonuses based on their implementation of specific processes to reduce errors and increase quality. They can earn up to $50 per year for each patient covered by a participating employer or plan. In addition, a report card for each physician office describes its performance on the program measures and is made available to the public. However, to date, transitional care has not been an explicit focus of this program.

3  

Dr. Eric Coleman is a member of this advisory group.

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

Nationwide, QIOs are involved with transitional care to an extent. The 8th Scope of Work focuses on providing health information technology assistance to physicians’ offices that could have application in improving communication and coordination across settings (CMS, 2004). QIOs are also in a position to examine “sentinel events” including consumer appeals for inappropriate or early hospital discharges and hospital readmissions for the same diagnosis. As described earlier, the Colorado Foundation for Medical Care has an initiative aimed at improving communication across hospitals and nursing homes regarding skin integrity and pressure ulcers. Lumetra, the QIO serving California, has initiated a Continuity of Care Collaborative that focuses on improving cross-setting communication for older patients following surgical repair (either elective or nonelective) of the hip. Members of the Collaborative are exploring measurement strategies around pain control (outcome) and completeness of information transfer (process) from both the perspective of the sending and receiving care providers. Delmarva, the QIO serving Delaware, Maryland, and Virginia, has been interested in transitional care as it relates to home health care. The Illinois Foundation for Quality Health Care is the quality improvement organization that has decided to work on a collaborative with the home health agencies focusing on acute hospitalizations. As of December 2004, 14 requests for the University of Colorado Health Sciences Center’s CTM have been received from 11 different QIOs (including those mentioned above).

HealthGrades has adopted AHRQ Patient Safety Indicators and released a report in July 2004 entitled HealthGrades Quality Study: Patient Safety in American Hospitals. However, among the 16 indicators, none were directly related to transitional care.

The Society for Hospital Medicine (SHM), with funding from the John A. Hartford Foundation, has initiated a project aimed at improving hospital discharge. In April 2005, SHM will hold a series of workshops that will review the evidence base, best practices, and conduct a modified Delphi consensus building process. The objective is for SHM members to take these idealized evidence-based practices back to their respective hospitals to implement quality improvement projects. The timing of this interest reflects the implementation of the JCAHO patient safety measures and Tracer Methodology described in detail below. Initiatives such as these will likely generate considerable demand for performance measures.

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

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

(Coleman and Fox, 2004). In addition to performance measurement, the report focuses on aligning financial incentives, ensuring accountability, implementing approaches to information transfer, and supporting patients, caregivers, and clinicians. To date, over 2200 reports have been requested.

The American Academy of Pediatrics (AAP) advocates for a Medical Home for children with special health needs (American Academy of Pediatrics, 2003). Communication of a core set of information and a common shared care plan across settings is a central component of the Medical Home. AAP also realizes that high-quality care for this population must include reimbursed time to review home health care orders for completeness and accuracy and to communicate changes in medications. At present, a comprehensive medication review and communication to involved practitioners can consume approximately 15 minutes which exceeds the time dedicated to a face-to-face visit. 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.

Finally, the JCAHO has deemed status for hospital discharge planning and continuity of care. Under statute, this requires JCAHO to assess the following representative care practices (Box I-2).

Encouraged by its Public Advisory Group, JCAHO has expressed interest in revising and strengthening its accreditation items in this area. To this end, JCAHO measurement leaders have held a series of telephone meetings with researchers from the University of Colorado Health Sciences Center to explore a possible collaboration.

In January 2004, JCAHO implemented a new approach to the survey process, Tracer Methodology (JCAHO, 2004b). This new approach includes the following elements: (a) following the course of care and services provided to a particular patient; (b) assessing relationships among disciplines and important functions; (c) evaluating the performance of relevant processes related to patient care; and (d) identifying potential vulnerabilities in care processes. It is now part of the typical 3-day on-site hospital survey process, and in most instances, a typical team of three surveyors is expected to complete approximately 11 tracers. The Tracer Methodology has not yet been extended beyond the hospital setting but it has potentially important implications for discharge planning and transitions. In particular, this approach can follow a particular patient, assessing how the patient fares along a continuum of care. It can assess how well the hospital staff has ascertained posthospital needs of a particular patient, the planning for discharge that has occurred, and, through patient interviews, assess the patient’s understanding about the postacute care aspects of his or her care.

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

BOX I-2
Hospital Discharge Planning and Continuity of Care Practices

  • The hospital must identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning.

  • The hospital must arrange for the initial implementation of the patient’s discharge plan.

  • As needed, the patient and family members or interested persons must be counseled to prepare them for posthospital care.

  • The hospital must transfer or refer patients, along with necessary medical information, to appropriate facilities, agencies, or outpatient services, as needed, for follow-up or ancillary care.

JCAHO has expressed an interest in using the University of Colorado Health Sciences Center’s three-item CTM to assess how well the hospital prepared patients to return to self-care at home.

JCAHO has adopted the accurate and complete reconcile medications across the continuum of care for one of its 2005 National Patient Safety Goals (JCAHO, 2004a). Full implementation will occur by January 2006. For 2005, hospitals will be encouraged to 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. A complete list of the patient’s medication is communicated to the next provider of service when it refers or transfers a patient to another setting, service, practitioner or level of care within or outside the organization. The Institute for Healthcare Improvement, with researchers from Luther Midlefort-Mayo Health System in Wisconsin, has sponsored learning collaboratives for participating health care systems in this area (Institute for Healthcare Improvement, 2004).

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

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

and support for clinicians in this area. These challenges are not insurmountable and in several cases, implementing performance measurement would be the exact stimulus needed to overcome these challenges.

Currently providers are not at financial risk for poor-quality transitional care. Few penalties exist for poor performance. For example, the hospital attending physician receives additional payment on the day of discharge irrespective of how well prepared the patient is to resume self-care. Alternatively it could be argued that providers are financially rewarded for poor quality to the extent that this care leads to recidivism and additional billing opportunities. While performance measurement in general and pay-for-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. Existing Medicare Conditions of Participation articulate these responsibilities but these have not been strongly enforced. Accountability also raises unprecedented questions as to whether two institutions that have no formal or fiscal relationships can be held jointly accountable for a failed transition. It also raises questions pertaining to the definition of an episode of care. However, as was alluded to above, this is a case in which answers to key questions such as these would follow once progress is made towards promoting greater accountability by enacting performance measurement.

Pay-for-performance discussions ultimately lead to discussions regarding case-mix adjustment. Currently performance measures oriented towards outcomes may not be sophisticated enough to discern whether a poor-quality care transition experience was due to a failed “hand-off” or simply a matter of disease progression. Experience with case-mix adjustment has been limited. This situation may argue for preferentially relying on process-oriented and patient experience-oriented measures versus more outcome-oriented measures. It may also argue for a two-staged approach in which, initially, health systems or institutions are paid for doing certain tasks rather than being paid for how they performed. For example, payment for timely transfer of a discharge summary, followed by timely transfer of a discharge summary that meets certain criteria for content and accuracy.

To date, pay-for-performance activities have focused on a set of measurement items that could be easily audited using administrative data sources. Yet as detailed earlier, the leading performance measurement instruments do not fit this profile and it is unlikely that such measures are possible given the current content of administrative records. For example, measures such as ACOVE or medication reconciliation rely on chart review that is often impractical for most health care systems to produce in a reliable and timely fashion (Wenger and Young, 2003). However, the emer-

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

gence of performance measurement in this area could potentially serve to foster greater adoption of health information technology, including expansion into postacute and long-term care settings.

Finally practitioners generally lack training on how to execute effective transfers and often do not recognize their role in transition planning. Compounding the problem is the fact that most practitioners have had little exposure to sites of care other than those in which they practice and are therefore unfamiliar with the ability of the receiving institution to manage complex patients. Practitioners require specific training to meet the needs of patients in transition and support systems that facilitate providing treatment, information, durable medical equipment, and other services during a patient’s transition. Once again, transitional care performance measurement may represent an effective stimulus for driving greater competency in this area. The SHM example of how professionals can organize to enhance professional competency and performance provided earlier was motivated, in part, to respond to changes in JCAHO accreditation.

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. In addition, although there has been some investigation to identify those patients at greatest risk for adverse events during care transitions (Coleman et al., 2004a,b), most practice-level initiatives have not preferentially focused on any specific subgroups. As such, these recommendations will not attempt to stratify the measurement population at interest, beyond patients making the transition of interest.

There has been a proliferation of measures in this area. However, this section will only address those measures that are deemed to be ready for “prime time” or in the language of the December 1st 2004 Workshop, “good” or “good enough.” As before, the focus remains on the care “hand-offs” that occur at the point of transition across different health care settings. Measures that attempt to capture a patient’s care coordination/care integration experience longitudinally are not at a level of sophistication where any recommendations can be made. Further, based on qualitative and quantitative studies on the areas most in need of quality improvement, the measures presented in this section reflect the key domains of 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.

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

Recommendations will be presented using the identical question and answer format requested by the Committee following the December 1st 2004 Workshop.

1. What measures are ready now for immediate implementation or within 1 year?

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. Please suggest a minimum of two that have a sufficient evidence base and have been tested for validity/reliability.

Based on the above criteria and the need for a sufficient evidence base, three measures could potentially be implemented within the upcoming year. All three measures reflect the patient’s experiences and rely on self-reported responses to items during either a telephonic or written survey. The exact wording of the items is provided in addition to a description of the measure.

PEP-C-II (see Table I-1) items were developed in partnership with NRC-Picker and were recently used in a survey of 200 hospitals/36,000 patients in California that included public reporting of scores for individual hospitals (California Healthcare Foundation, 2004). These items meet the above-stated criteria with the exception that they are hospital-specific and the NRC-Picker items are proprietary. As this survey focused on the overall hospital care experience, it is not known whether quality improvement projects aimed at transitions out of the hospital have been initiated in Cali-

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

TABLE I-1 Patients’ Evaluation of Performance in California Survey (PEP-C-II)(CHCF)

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?

fornia. NRC may retain proprietary rights to the items. The items have not been endorsed by NQF.

The development of the CTM (see Table I-2) was explicitly guided by the reported experiences of patients with complex care needs and their family caregivers (Coleman et al., 2004d). Thus the items directly reflect the key patient-centered domains stated earlier. Although the above items include wording for the hospital, CTM items have been used across a variety of care “hand-offs.” CTM scores have been shown to predict rates of rehospitalization and return to the emergency department. They have also been shown to discriminate among hospitals known to differ in their commitment to quality improvement in this area. 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. In addition, over 70 requests for the CTM have been received, including 11 different QIOs interested in the CTM for possible implementation in local quality initiatives. A “head-to-head” testing of CTM items and HCAHPS items is under way and results will be available in Spring 2005. In response to comments from NQF, a

TABLE I-2 Care Transitions Measure (CTM)

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.

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

next round of testing will soon be under way to test the CTM in more diverse patient populations. To date, 74 requests from this measure have been received from health care delivery systems, QIOs, quality improvement entities and academic researchers from the United States and abroad. The CTM meets the criterion stated above and is being submitted as part of the NQF call for measures under the National Voluntary Consensus Standards for Hospital Performance initiative.

The HCAHPS initiative has great potential for uniform data collection for hospitals nationwide (AHRQ, 2003). The two discharge planning items (see Table I-3) have remained despite tremendous pressure from industry to reduce the number of items. Understandably, HCAHPS are hospital specific. HCAHPS two items were the lowest performers of all of the HCAHPS items in an external validation testing phase (CAHPS II Investigators and AHRQ, 2003). To date, A-CAHPS does not have items specific to care hand-offs. 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. Item 1 does not appear to be clearly actionable (i.e., it asks whether a hospital staff member talked to the patient but does not convey whether the staff member acted on this discussion). The items will be submitted for consideration through NQF call for measures to be considered through the Consensus Development Process.

1b. How would you implement them in a way that is feasible?

Currently, nearly every hospital in the country conducts a patient-reported survey of the hospital experience. To date, the area of transitional care has been underrepresented. These items could be incorporated into/supplement these efforts.

2. What measures in your specific area are “nearly there” requiring only modest tweaking?

TABLE I-3 HCAHPS® (AHRQ)

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?

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

TABLE I-4 The Assessing Care of Vulnerable Elders Measure (ACOVE)

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.

The measures proposed in the prior section are based on patient report. Transitional care performance measurement would be complemented by the inclusion of process of care measures that examine care processes believed to be associated with high-quality care. ACOVE measures (see Table I-4) were developed for this purpose (Wenger and Young, 2003). Formal psychometric testing is limited and further testing may help “tweak” these items to be almost ready. Further testing might also explore whether these items can discriminate among providers and whether they are associated with outcomes such as recidivism. The primary limitation of these items is that they require chart review.

LOOKING AHEAD: ADDRESSING CURRENT GAPS

Advancing the current “state of the science” with respect to transitional care will require that a number of the current gaps be addressed. The first involves refinement for how an episode of care is defined as it relates to transitional care. Patients with complex care needs frequently make multiple transitions and there is a need to better isolate the episode of care in order to assess performance, particularly as it relates to accountability and potentially financial reward. Similarly, a broader number of care transitions will need to be included, beyond hospital to skilled nursing facilities or hospital to home. Protocols are needed that account for the growing prevalence of cognitive impairment among the population of patients at

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

risk for poor-quality care transitions. Testing in more diverse populations is needed, including for those residing in rural settings where the risks of poor “hand-offs” may be even greater due to geographic distances. 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. As mentioned earlier, it will be particularly important to not only capture whether information is made available but whether the information has been incorporated into the care plan where it would have the potential to positively influence health care outcomes. Finally, throughout this report, the interest and activities among the nation’s QIOs have been highlighted. The QIOs are uniquely positioned to play a leadership role in the design and execution of performance measurement efforts that extend beyond a single care setting. The timing appears ideal for CMS to play a leadership role in galvanizing this momentum from a series of individual projects into a nationwide quality improvement effort aimed at expanding the role of performance measurement in improving the quality of transitional care.

REFERENCES

ARHQ (Agency for Healthcare Research and Quality). 1999. Outcomes by Patient and Hospital Characteristics for All Discharges. [Online]. Available: http://www.ahrq.gov/HCUPnet.asp [accessed June 29, 2004].

AHRQ. 2003. Update on hospital CAHPS (HCAHPS). [Online]. Available: http://www.ahrq.gov/qual/cahps/hcahpsupdate.htm. [accessed June 29, 2004].

American Academy of Pediatrics. 2003. What Is a Medical Home? The National Center of Medical Home Initiatives for Children with Special Needs. [Online]. Available: http://www.medicalhomeinfo.org/ [accessed January 3, 2005].

Anderson MA, Helms LB. 1995. Communication between continuing care organizations. Research in Nursing and Health 18:49–57.

ASTM (American Society for Testing and Materials International), Massachusetts Medical Society, Health Information Management and Systems Society, and American Academy of Family Physicians. 2003. Continuity of Care Record (CCR) The Concept Paper of the CCR. [Online]. Available: http://www.bhtinfo.com/CCR.Concept%20Paper.1.5.docVersion1.5. [accessed January 12, 2005].


Bazzoli G, Brewster L, Liu G, Kuo S. 2003. Does U.S. hospital capacity need to be expanded? Health Affairs 22:40–54.

Beers M, Sliwkowski J, Brooks J. 1992. Compliance with medication orders among the elderly after hospital discharge. Hospital Formulary 27:720–724.

Boockvar K, Fishman E, Kyriacou CK, Monias A, Gavi S, Cortes T. 2004. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Archives of Internal Medicine 164:545–550.

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

Brewster LR, Rudell LS, Lesser CS 2001. Emergency Room Diversions: A Symptom of Hospitals Under Stress. Issue Brief. Washington, DC: Center for Studying Health System Change.


CAHPS. 2004. Child Health Plan Survey: Composites for Children with Chronic Conditions. [Online]. Available: http://www.cahps-sun.org/Products/Healthplan/HPCCC-Composite.asp#coc [accessed January 3, 2005].

CAHPS II Investigators and Agency for Healthcare Research and Quality (AHRQ). 2003. HCAHPS Three-state Pilot Study Analysis Results. [Online]. Available: http://www.cms.hhs.gov/quality/hospital/3State_Pilot_Analysis_Final.pdf [accessed January 3, 2005].

California Health Care Foundation. 2004. California Hospital Experience Survey Executive Summary. [Online]. Available: http://www.chcf.org/documents/hospitals/CAHospitalExpSurvey04ExecSum.pdf [accessed January 3, 2005].

CMS (Centers for Medicare and Medicaid Services). 2004. Proposed Summary of Draft 8th Statement of Work for Quality Improvement Group. [Online]. Available: http://www.cms.hhs.gov/qio/2s.pdf [accessed January 3, 2005].

CMS. 2002. 7th Statement of Work: Joint Commission on Accreditation of Healthcare Organizations. Heart failure: Percent of patients discharged home with written discharge instructions or educational material. [Online]. Available: http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?doc_id=436&string=heart+AND+failure+AND+patients+AND+discharged+AND+home [accessed January 3, 2005].

Coleman EA. 2003. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatric Society 51:549–555.

Coleman EA, Berenson RA. 2004. Lost in transition: Challenges and opportunities for improving the quality of transitional care. Annals of Internal Medicine 141:533–536.

Coleman EA, Boult C. 2003. Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society 51:556–557.

Coleman EA, Fox PD. 2004. One Patient, Many Places: Managing Patient Transitions of Care. [Online]. Available: http://www.aahp.org/Content/NavigationMenu/Inside_AAHP/Care_Management1/Care_Management.htm [accessed October 24, 2004].

Coleman EA, Holthaus D, Johnson MF, Eilertsen TB, Kramer AM. 1999 Development of a quality measurement instrument for post-acute care. 1–17. Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services.

Coleman EA, Eilertsen TB, Smith JD, Frank J, Thiare JN, Ward A, Kramer AM. 2002. Development and testing of a measure designed to assess the quality of care transitions. International Journal of Integrated Care Vol. 2. [Online] Available: http://www.ijic.org [accessed October 15, 2004]

Coleman EA, Foley C, Phillips C. 2003. Falling through the cracks: Practical strategies for reducing adverse events among older patients transferring between sites of care. Annals of Long Term Care 11:33–36.

Coleman EA, Min S, Chomiak A, Kramer AM. 2004a. Post-hospital care transitions: patterns, complications, and risk identification. Health Services Research 39:1449–1465.

Coleman EA, Smith JD, Raha D, Min S. 2004b. Post-hospital medication discrepancies: Prevalence, types, and contributing system-level and patient-level factors. Gerontologist 44[Spec. Issue 1], Abstract #1406.

Coleman EA, Smith JD, Frank JC, Min S, Parry C, Kramer AM. 2004c. Preparing patients and caregivers to participate in care delivered across settings: The Care Transitions Intervention. Journal of the American Geriatric Society 52:1817–1825.

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

Coleman EA, Mahoney E, Parry C. 2004d. Assessing the quality of preparation for post-hospital care from the patient’s perspective: The care transitions measure (CTM). Medical Care 43(3) 246–255.


Dudas V, Bookwalter T, Kerr KM, Pantilat SZ. 2001. The impact of follow-up telephone calls to patients after hospitalization. American Journal of Medicine 111:26S–30S.


Forster A, Murff H, Peterson J, Gandhi T, Bates D. 2003. The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of Internal Medicine 138:161–167.


Gazmararian JA, Baker DW, Williams MV, Parker RM, Scott TL, Green DC, Fehrenbach SN, Ren J, Koplan JP. 1999. Health literacy among Medicare enrollees in a managed care organization. Journal of the American Medical Association 281:545–551.

Grimmer K, Moss J. 2001. The development, validity and application of a new instrument to assess the quality of discharge planning activities from the community perspective. International Journal of Quality in Health Care 13:109–116.

Grimmer KA, Moss JR, Gill TK. 2000. Discharge planning quality from the care perspective. Quality of Life Research 9:1005–1013.


Harrison A, Verhoef M. 2002. Understanding coordination of care from the consumer’s perspective in a regional health system. Health Services Research 37:1031–1054.

Hendriks A, Vrielink M, Smets E, van Es S, De Haes J. 2001. Improving the assessment of (In)patients’ satisfaction with hospital care. Medical Care 39:270–283.

Hibbard JH, Stockard J, Mahoney ER, Tusler M. 2004. Development of the patient activation measure (PAM): Conceptualizing and measuring activation in patients and consumers. Health Services Research 39:1005–1026.


Institute for Healthcare Improvement. 2004. Medication Reconciliation Flowsheet. [Online]. Available: http://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/Tools/Medication+Reconciliation+Review.htm [accessed January 3, 2005].

IOM (Institute of Medicine). 2000. To Err Is Human: Building A Safer Health System. Washington, DC: National Academy Press.

IOM. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press.

IOM. 2003. Key Capabilities of an Electronic Health Record System. Washington, DC: The National Academies Press.

IOM. 2004. The 1st Annual Crossing the Quality Chasm Summit. Adams, K, Greiner, AC, Corrigan, JM, eds. Washington, DC: The National Academies Press.


JCAHO (Joint Commission on Accreditation of Healthcare Organizations). 2001. Standards and Intent Statements-Section 1: Patient-Focused Functions. Hospital Accreditation Standards. Joint Commission on Accreditation of Healthcare Organizations. Pp. 69–156.

JCAHO. 2004a. 2005 Hospitals’ National Patient Safety Goals. [Online]. Available: http://www.jcaho.org/accredited+organizations/patient+safety/05+npsg/05_npsg_hap.htm [accessed January 1, 2005].

JCAHO. 2004b. Shared Visions - New Pathways Q&A. New pathway: Tracer methodology. [Online]. Available: http://www.jcaho.org/accredited+organizations/svnp/svnp+qa_tracer+methodology.htm [accessed January 1, 2005].


Katz T, Walke L, Jacobs L. 2000. A geriatric hospitalist program for nursing home residents. Annals of Long Term Care 8:51–56.

Kiely DK, Bergmann MA, Murphy KM, Jones RN, Orav EJ, Marcantonio ER. 2003. Delirium among newly admitted postacute facility patients: prevalence, symptoms, and severity. Journal of Gerontology Series A-Biological Sciences and Medical Sciences 58:M441–M445.

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

Kramer A, Eilertsen T, Lin M, Hutt E. 2000. Effects of nurse staffing on hospital transfer quality measures for new admissions. Pp. 9.1–9.22. In Appropriateness of Minimum Nurse Staffing Ratios for Nursing Homes. Health Care Financing Administration.

Kramer AM, Bennett R, Fish R, Lin CT, Floersch N, Conway K, Coleman EA. 2004. Case Studies of Electronic Health Records in Post-Acute and Long-Term Care - Final Report. Office of Disability, Aging, and Long-Term Care Policy. U.S. Department of Health and Human Services [Contract Number:233-02-0070], 1–141.


Levine C. 1998. Rough Crossings: Family Caregivers Odysseys Through the Health Care System. New York: United Hospital Fund of New York.


Moore C, Wisnevesky J, Williams S, McGinn T. 2003. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. Journal of General Internal Medicine 18:646–651.

Mor V, Murphy J, Masterson-Allen S, Willey C, Razmpour A, Jackson M, Greer D, Katz S. 1989. Risk of functional decline among well elders. Journal of Clinical Epidemiology 42:895–904.


Naylor M, Brooten D, Campbell R, Jacobsen B, Mezey M, Pauly M, Schwartz J. 1999. Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. Journal of the American Medical Association 281:613–620.

NCQA (National Committee for Quality Assurance). Follow-up after Hospitalization for Mental Illness: 7 Days and 30 Days. The State of Health Care Quality: 2004. [Online]. Available: http://www.ncqa.org/communications/SOMC/SOHC2004.pdf [accessed January 3, 2005].


Oregon Health and Science University Center for Ethics and Health Care. 1996. The Physician Orders for Life-Sustaining Treatment Program (POLST). [Online]. Available: http://www.ohsu.edu/ethics/polst/ [accessed January3, 2005].


Partnership for Solutions. 2002. Chronic Conditions: Making the Case for Ongoing Care. Baltimore MD: The Johns Hopkins University.


Reiss J, Gibson R. 2002. Health care transition: Destinations unknown. Pediatrics. 110:1307–1314.

Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, Carney RM. 1995. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. New England Journal of Medicine 333:1190–1195.


Stewart S, Pearson S, Horowitz J. 2000. Effects of a home-based intervention among patients with congestive heart failure discharged from acute hospital care. Archives of Internal Medicine 158:1067–1072.


U.S. DHHS (United States Department of Health and Human Services). 2000. Analysis of Readmissions Under the Medicare Prospective Payment System for Calendar Years 1996 and 1997. Office of Inspector General, DHHS. [Online]. Available: http://www.oig.hhs.gov/reports.html [accessed October 24, 2004].


van Walraven C, Seth R, Austin PC, Laupacis A. 2002a. Effect of discharge summary availability during post-discharge visits on hospital readmission. Journal of General Internal Medicine 17:186–192.

van Walraven C, Seth R, Laupacis A. 2002b. Dissemination of discharge summaries. Not reaching follow-up physicians. Canadian Family Physician 48:737–742.

vom Eigen K, Walker J, Edgman-Levitan S, Cleary P, Delbanco T. 1999. Carepartner experiences with hospital care. Medical Care 37:33–38.


Wachter R, Goldman L. 2002. The hospitalist movement 5 years later. Journal of the American Medical Association 287:487–494.

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

Weaver FM, Perloff L, Waters T. 1998. Patients’ and caregivers’ transition from hospital to home: Needs and recommendations. Home Health Care Services Quarterly 17:27–48.

Wenger NS, Young R. 2003. Quality Indicators for Continuity and Coordination of Care in Vulnerable Elders. [Online]. Available: http://www.acponline.org/sci-policy/acove/ [accessed January 3, 2005].

Wolff JL, Starfield B, Anderson G. 2002. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Archives of Internal Medicine 162:2269–2276.

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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.

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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)?

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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.

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×

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.

Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 250
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 251
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 252
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 253
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 254
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 255
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 256
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 257
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 258
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 259
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 260
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 261
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 262
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 263
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 264
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 265
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 266
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 267
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 268
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 269
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 270
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 271
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 272
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 273
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 274
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 275
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 276
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 277
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 278
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 279
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 280
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 281
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 282
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 283
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 284
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 285
Suggested Citation:"Appendix I Commissioned Paper: Transitional Care Performance Measurement--Eric A. Coleman." Institute of Medicine. 2006. Performance Measurement: Accelerating Improvement. Washington, DC: The National Academies Press. doi: 10.17226/11517.
×
Page 286
Next: Appendix J Commissioned Paper: Palliative Care/End-of-Life Measures--Sydney Dy and Joanne Lynn »
Performance Measurement: Accelerating Improvement Get This Book
×
Buy Hardback | $75.00
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

Performance Measurement is the first in a new series of an ongoing effort by the Institute of Medicine (IOM) to improve health care quality. Performance Measurement offers a comprehensive review of available measures and introduces a new framework to examine these measures against the six aims of the health care system: health care should be safe, effective, patient-centered, timely, efficient, and equitable. This new book also addresses the gaps in performance measurement and introduces the need for measures that are longitudinal, comprehensive, population-based, and patient-centered. This book is directed toward all concerned with improving the quality and performance of the nation’s health care system in its multiple dimensions and in both the public and private sectors.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    Switch between the Original Pages, where you can read the report as it appeared in print, and Text Pages for the web version, where you can highlight and search the text.

    « Back Next »
  6. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  7. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  8. ×

    View our suggested citation for this chapter.

    « Back Next »
  9. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!