Measuring What Matters: Care Transitions

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Measuring What Matters Care Transitions

• Karen Adams, PhD
• Senior Program Officer
• National 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 govt to adopt voluntary
  consensus standards if establishing standards
• Encourages the federal govt 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 efficiencydefined as quality and
  costsacross 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 DomainsMeasuring 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

• Post AMI Trajectory 1 (T1)
• Relatively healthy adult
• Focus on
• Quality of Life
• Functional Status
• 20 Prevention Strategies
• Rehabilitation
• Advanced care planning

Population at Risk 10 Prevention (no known
CAD) 20 Prevention (CAD no prior AMI)
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Context for Considering aLow Back Pain Episode

• 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
• 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.

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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

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Questions/Comments

• kadams_at_qualityforum.org