Centre for Research in Geriatric Medicine D EVELOPMENT OF Q UALITY I NDICATORS FOR O LDER P EOPLE I N T RANSITION C ARE

Centre for Research in Geriatric Medicine Investigators & Funding  Investigators –Professor Len Gray, The University of Queensland –Professor Ian Cameron, University of Sydney –Professor Maria Crotty, Flinders University –Dr Nancye Peel, The University of Queensland  Consultants –Professor John Morris, Hebrew Senior Life, Boston, USA –Professor Richard Jones, Harvard Medical School, Boston, USA  Funding –NHMRC Health Services Research Program Grant

Centre for Research in Geriatric Medicine Research Aims  To develop and validate a suite of Quality Indicators (QIs) applicable to older persons in transition from acute care to the community  To undertake an economic analysis to assess the clinical outcomes and resource implications of the program.

Centre for Research in Geriatric Medicine Why Quality Indicators?  Internal monitoring of quality, basis for quality improvement strategies  Inter-service benchmarking  Quality monitoring by funding agencies  Public accountability, including aiding consumer choice Need for greater accuracy

Centre for Research in Geriatric Medicine Target Audience(s)  Programs –Complex community based post acute programs, serving older people  Stakeholders –Primarily service providers and their staff –Secondary audiences Funders of services Consumers  Designed for international relevance

Centre for Research in Geriatric Medicine Criteria for high quality QIs  Indicators conform with expert opinion of good outcomes  Indicators reflect best evidence of good outcomes  Based on robust, reliable observations  Prevalence > 5% & < 95%  Accommodate variation in caseload between services (risk adjusted)  Discriminate between best and worst performing services  Can be collected at low cost

Centre for Research in Geriatric Medicine Three broad categories of QIs  Outcome Indicators- focus on what is achieved o Examine direct outcomes of care  Process Indicators- focus on what is done o Examine whether processes are conducted at an individual level which are known to be associated with good outcomes  Structural Indicators- focus on what is needed o Examine the policies, resources, design features, etc, at an organisational level to ensure appropriate care process and outcomes

Centre for Research in Geriatric Medicine QI focus in TCP study  To develop and validate “outcome oriented” QIs for older people in transition care. ( A set of QIs has been developed in North America based on interRAI Home Care assessments)  To compare above with the assessments of quality derived from process indicators. (A set of process QIs, ACOVE‐3, has recently been developed in the USA for community‐dwelling vulnerable elders).  To explore predictors of quality among participating transition care program sites  To examine the cost of collection of each format of QIs

Centre for Research in Geriatric Medicine Study Plan: Phase 1 Development of a Provisional Set of QIs  Develop draft QI set based on literature review, best practice guidelines pertaining to geriatric outcomes in post acute/ subacute care  Review by Expert Panel (geriatricians, rehabilitation specialists, allied health practitioners, service providers, research academics, policy analysts)  Refine to conceptualise a set of QIs for the TCP derived from the interRAI HC and ACOVE 3 systems and available administrative data

Centre for Research in Geriatric Medicine The Expert Panel: Objectives  Workshop 1 (May 2009) –To review clinical domains of importance to older people in transition care –To establish best practice (based on published evidence and expert opinion) for care of older patients in transition care –To advise on potential QIs to underpin data collection in the Field Study  Workshop 2 (Nov 2010) –To examine results of the field study and provide advice on final QI data set(s)

Centre for Research in Geriatric Medicine QI domains  Physical functioning, falls and mobility  Cognition and emotional health  Social functioning  Nutrition  Medication & pain management  Skin integrity & continence  Continuity of care & goal attainment

Centre for Research in Geriatric Medicine QI Examples DomainQITypeDenominatorNumerator Physical FunctionFailure to improve/ incidence of decline in self-care Activities of Daily Living (ADL) OutcomeAll clientsClients who have some impairment on ADL and who fail to improve/ remain the same on discharge or who develop a new ADL impairment Physical Function Assessment of physical function at admission ProcessAll clientsClients with documented evidence of objective physical function assessment (including self-care) using a validated tool (eg Modified Bartel Index; Katz; FIM) within 24 hours of admission

Centre for Research in Geriatric Medicine Study Plan: Phase 2 Field testing  6 community-based TC sites, 2 states (QLD & SA), approx 400 cases  Collecting prospective clinical data using interRAI HC assessment for outcome QIs  Completing a file audit for process QIs (based on ACOVE QIs)

Centre for Research in Geriatric Medicine Study Plan- Phase 3 Analysis and final consultation  QIs adjusted for ascertainment and selection bias through risk adjustment procedures  expert panel reconvened to consider the findings of the field study, and assembly of the final QI set and associated recommendations.  site coordinators will be invited to a final consultation meeting for an opportunity to contribute to the quality framework and benchmarking for their programs.  preparation of a formal report in addition to publications for the peer-reviewed literature