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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

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Questions/Comments

kadams@qualityforum.org