Measuring What Matters: Care Transitions
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Transcript of Measuring What Matters: Care Transitions
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Measuring What Matters: Care Transitions
Karen Adams, PhD Senior Program OfficerNational Quality Forum
February 4, 2008
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History & Background
• Established in 1999
• Non-profit
• Multi-stakeholder membership organization
• Voluntary, consensus standard setting organization
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National Technology Transfer and
Advancement Act of 1995
• Defines 5 attributes of a voluntary consensus standards setting body– Openness– Balance of interest– Due process– Consensus, appeals process
• Obligates federal gov’t to adopt voluntary consensus standards if establishing standards
• Encourages the federal gov’t to participate in setting voluntary consensus standards
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New Mission Statement
To improve the quality of American healthcare by • setting national priorities and goals for
performance improvement, • endorsing national consensus standards for
measuring and publicly reporting on performance, and
• promoting the attainment of national goals through education and outreach programs.
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Priority Setting Pilot Project
Kevin Weiss, MD Co-chair Elliott Fisher, MD Co-chair
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Priority SettingPilot Project
• Developed a comprehensive measurement framework to evaluate efficiency—defined as quality and costs—across episodes of care including:– Clear definitions– A discrete set of domains – Guiding principles for implementation
• Selected two priority conditions - AMI & LBP - to serve as operational examples to measure, report and improve efficiency across episodes of care
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Rationale for Episode of Care Approach
• Supports a patient-centered approach• Addresses major gaps in existing performance
measures: care transitions, patient-centered & cost of care measures
• Shifts focus from individual providers’ performance to understanding their contribution to care: “shared accountability”
• Required to understand costs and their relationship to quality
• Could support reformed payment models
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Framework Domains:Measuring What Matters
• Patient-level outcomes– Morbidity and mortality– Functional status– Health related quality of life– Patient experience with care
• Processes of care– Technical – Care coordination/transitions – Decision support
• Cost and resource use – Total cost of care across the episode– Opportunity costs to patients
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Operational Examples
• AMI• Well defined diagnostic
and treatment strategies• Acute care example with
chronic care implications• Portfolio of endorsed
measures• Opportunity to
demonstrate hand-offs across multiple settings
• Low Back Pain • Preference sensitive
condition• Opportunity to target
overuse• Opportunity to highlight
shared-decision making and informed choice
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Context for Considering an AMI Episode
Getting BetterLiving w/ Illness/Disability (T1)
Coping w/ End of Life (T2)Staying Healthy
Post Acute/Rehabilitation Phase
20 Prevention
Episode begins – onset of symptoms
Post AMI Trajectory 2 (T2)Adult with multiple co-morbidities
Focus on:• Quality of Life• Functional Status• 20 Prevention Strategies• Advanced Care Planning• Advanced Directives• Palliative Care/Symptom Control
Assessment ofPreferences
AcutePhase
PHASE 1
PHASE 2 PHASE 3 PHASE 4
Episode ends – 1 year post AMI
20 Prevention(CAD with prior AMI)Advanced Care Planning
Population at Risk
10 Prevention (no known CAD)
20 Prevention (CAD no prior AMI)
Post AMI Trajectory 1 (T1)Relatively healthy adult
Focus on:• Quality of Life• Functional Status• 20 Prevention Strategies• Rehabilitation• Advanced care planning
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Context for Considering aLow Back Pain Episode
Getting BetterStaying Healthy (T1)
Living w/ Illness/Disability (T2)
Confirm back painsyndrome; Rule out red flags
(i.e. malignancy, infection)
Follow-up Care & Prevention
Episode begins – onset of symptoms
Trajectory 2 (T2) Patient at risk for long-term chronic disability
Focus on:• Quality of Life• Functional Status• Patient-generated goals
Population at Risk
Adults with back pain
Surgery or MedicalTreatment
Episode ends – 1 year
Patient baseline assessment of function,
mental health & comorbidities
PHASE 1
PHASE 2
PHASE 4 PHASE 5PHASE 3
Shared Decision Making & Informed Choice
Trajectory 1 (T1) Returning back to work & assuming normal activities of daily living
Focus on:• Quality of Life• Functional Status• Patient-generated goals• Education & prevention
of future episodes
Diagnosis & Initial Management
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NQF Endorsed Care Transition Measure• Care Transitions Measure: CTM-3
Developed by Eric Coleman Include 3 patient questions answered on a 5-
point scale 1.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.
2.When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
3.When I left the hospital, I clearly understood the purpose for taking each of my medications.
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Care Coordination Framework
• NQF endorsed Care Coordination Framework has five key dimensions:
– Healthcare “Home”– Proactive Plan of Care & Follow-up– Communication – Information systems– Transitions or Hand-offs
• Care coordination conference on March 27 & 28 to further flesh out measurement in each of these domains
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NQF Endorsed Medication Reconciliation Measures
• Percentage of patients aged 65 years and older discharged from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) and seen within 60 days following discharge in the office by the physician providing on-going care who had a reconciliation of the discharge medications with the current medication list in the medical record documented. (NCQA, PCPI, AGS)
• Drugs to be avoided in the elderly: a. Patients who receive at least one drug to be avoided, b. Patients who receive at least two different drugs to be avoided. (NCQA)
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Readmission measures under review at NQF
• All-Cause Readmission Index (PacifiCare)– Total inpatient readmissions within 30 days from
discharge to any hospital
• 30-Day All-Cause Risk Standardized Readmission Rate Following Heart Failure Hospitalization (CMS/Yale)– Heart failure 30-day all cause readmissions
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Not everything that counts can be counted, and not
everything that can be counted counts.
Albert Einstein