1. Emergency Department Transfer Communication (EDTC)
February 7th 2017
Presented By: Shanelle Van Dyke

2. Agenda Introduction Rationale & Background Project Summary Measures
Understand connection to Medicare Beneficiary Quality Improvement Project (MBQIP)
Measures
ED Transfer Communication Training - Data Collection and Reporting
Review EDTC Data Collection Guide Specifications
Navigation and Use of EDTC Data Collection Tool
Data Entry and Report Generation Tutorial
Brief Overview of EDTC Data Collection Tool Manual

3. Introduction
There are 1,332 Critical Access Hospitals in the United States, a special designation for small rural hospitals -- with a limited scope of services, 25 or fewer hospital beds, and geographically isolated -- serving as an acute care safety net for rural residents.
CAHs meet the basic acute care needs for their rural communities and service areas, for example, pneumonia and heart failure care.
They also provide crucial stabilize-and-transfer functions when patients with more complex needs and conditions, such as AMI/heart attack, stroke, or trauma arrive in their emergency rooms.
For example, when a patient arrives at a CAH emergency department needing care and services, especially time-sensitive care, that the CAH does not provide, the CAH’s ability to assess, decide to transfer, and get the patient out the door with the necessary and appropriate information can be life or death.
Data indicating how well a CAH serves this important stabilize-and- transfer role was not currently widely available.
There are 1,332 Critical Access Hospitals in the United States, a special designation for small rural hospitals -- with a limited scope of services, 25 or fewer hospital beds, and geographically isolated -- serving as an acute care safety net for rural residents. While any single CAH does not serve a large number of patients on any given day, in 2009 CAHs accounted for 417,000 Medicare inpatient stays not including swing bed and 11.2 million outpatient claims, reflecting an important component of care delivery in this country.
CAHs meet the basic acute care needs for their rural communities and service areas, for example, pneumonia and heart failure care. They also provide crucial stabilize-and-transfer functions when patients with more complex needs and conditions, such as AMI/heart attack, stroke, or trauma arrive in their emergency rooms. For example, when a patient arrives at a CAH emergency department needing care and services, especially time-sensitive care, that the CAH does not provide, the CAH’s ability to assess, decide to transfer, and get the patient out the door with the necessary and appropriate information can be life or death.
Data indicating how well a CAH serves this important stabilize-and-transfer role was not currently widely available.

4. Rationale
Appropriate measures are needed to evaluate care in rural hospitals
Nationally, all large hospitals are required to publicly report a set of core measures indicating their performance in providing quality care.
Many of the publicly reported measures are not relevant to the low-volume of services provided by CAHs. Low volumes results in unreliable data and some measures are for services not provided at CAHs.
While emergency care is important in all hospitals, the emergency department is particularly important in rural hospitals where the distance to urban tertiary care centers makes the effective triage, stabilization, and transfer of patients with the necessary and appropriate information of life or death importance.
ED transfer communication measures allow the acute care safety net facilities to show how well they carry out their important stabilize-and-transfer role for rural residents. Minnesota requires quality reporting of critical access hospitals. CAHs in other states also may want to measure their own performance in providing quality care.
Nationally, all large hospitals are required to publicly report a set of core measures indicating their performance in providing quality care. Many of the publicly reported measures are not relevant to the low-volume of services provided by CAHs. Low volumes results in unreliable data and some measures are for services not provided at CAHs.
While emergency care is important in all hospitals, the emergency department is particularly important in rural hospitals where the distance to urban tertiary care centers makes the effective triage, stabilization, and transfer of patients with the necessary and appropriate information of life or death importance. ED transfer communication measures allow the acute care safety net facilities to show how well they carry out their important stabilize-and-transfer role for rural residents. Minnesota requires quality reporting of critical access hospitals. CAHs in other states also may want to measure their own performance in providing quality care.
The ED transfer communication measures (EDTC) were originally developed by Stratis Health and the University of Minnesota Rural Health Research Center and were originally endorsed by the National Quality Forum in 2007.

5. Background ED Transfer Communication Special Innovation Project
Stratis Health led a one-year national special innovation project funded by the Centers for Medicare & Medicaid Services for critical access hospitals in eight states to improve transitions of care during ED transfers (August July 2014).
Stratis Health supported eight Medicare Quality Improvement Organizations, working collaboratively with their state Medicare Rural Hospital Flexibility Program (Flex) offices, to train CAHs to collect and report seven composite ED transfer communication measures, identify gaps and opportunities for improvement, and begin planning to improve the transfer communication process and results. States included Iowa, Maine, Missouri, Nebraska, Oklahoma, West Virginia, Wisconsin, and Wyoming.
Participating CAHs abstracted medical records to collect data on the EDTC measures. CAHs submitted data through their QIOs to Stratis Health for benchmarking with other participating facilities.
In 2003, CMS selected Stratis Health, the Medicare QIO for Minnesota, to lead a Special Study to identify and field test rural relevant hospital measures. Stratis Health led the study: Refining and Field Testing a Relevant Set of Quality Measures for Rural Hospitals, in partnership with the University of Minnesota Rural Health Research Center and HealthInsight, the QIO for Utah and Nevada. In the study, staff from 22 hospitals in three states (Minnesota, Utah, and Nevada) were trained by Stratis Health and its partners to collect a variety of inpatient, outpatient, and administrative measures of relevance to rural hospitals including, for the first time, the Emergency Department (ED) Transfer Communication Tool, which was developed for the study using the Continuity of Care Record (CCR). As part of the study, a national Technical Expert Panel provided input and insight on both the design of the study and the findings. The study’s final report in 2005 stated in part:
“The transfer communication measure appears very promising. Pilot hospitals found it useful and relevant. Several hospitals have been inspired by the measurement process to improve their systems of transfer communications. In this study the measure only addressed transfers from the referring hospital’s ED to the tertiary hospital. This measure’s combination of administrative information, patient identification, and patient care information can also be applied to any transfer of care of admitted patients. Perhaps with minor modifications the transfer communication measure could be relevant to transfers to nursing homes and referrals to home health agencies.
Information on all 16 components of the measure is useful for hospital quality improvement. For external comparisons, a summary score such as the average number of components present may suffice.”
Subsequent to the CMS Special Study, the University of Minnesota successfully put the ED Transfer Communication Measure through the NQF (National Quality Forum) endorsement process in The measure is also now part of the HRSA Office of Rural Health Policy’s (ORHP) Medicare Rural Hospital Flexibility Program (Flex) priorities in the Medicare Beneficiary Quality Improvement Project (MBQIP).

6. Background Continued…
RESULTS! Critical access hospitals improved process measures—56% relative improvement rate!!!
Participating CAHs increased their percentage of medical records meeting all of the EDTC data elements over the course of the project from 28.26% to % —for a relative improvement rate of 56%
The hospitals used the results to develop and implement improvements focused on better documentation and communication processes
Rural hospitals were trained to collect information on emergency department transfer communication, and use the data to improve quality of care, safety, and outcomes for patients transferred from their emergency departments
Emergency Department Transfer Communication - Special Innovation Project Final Summary Report (15-page PDF)

7. Project Summary
The Critical Access Hospital (CAH) Emergency Department Transfer Communication (EDTC) project is intended to build Flex capacity to support and improve the care delivered by CAHs focusing on transfer communication from the CAH emergency department.
These National Quality Forum (NQF) endorsed measures are available for hospitals to evaluate communication for transitions of care during emergency department (ED) transfers.
These ED transfer communication measures is particularly relevant for critical access hospitals (CAHs), and is included in the Medicare Beneficiary Quality Improvement Project (MBQIP).
Starting fall 2014, CAHs nationwide can collect and submit the measure. MBQIP is a program of the Health Resources and Services Administration (HRSA) funded Office of Rural Health Policy’s (ORHP) Medicare Rural Hospital Flexibility Program (Flex).

8. Measure Overview
Emergency Department Transfer Communication Measures Required Data Elements
The National Quality Foundation (NQF) endorsed ED Transfer Communication Measure consists of a series of 27 sub-measures, reflecting 7 domains. Relevant measures reflect: (a) decision-making and protocol availability and their use in decisions about where to treat a patient; (b) processes for stabilizing and transporting patients; and (c) care integration with referral hospitals and other care delivery systems.
Hospital results can be calculated using different methods:
Calculate the 7 categories using an all-or-none approach which is simpler to report and provides a single score.
Calculate a score on all 27 sub-categories for a “credit given when earned” approach. This approach helps define opportunities for improvement and inform strategies
Each of the seven measures is calculated using an all-or-none approach. Data elements are identified for each
measure. If the data element is not appropriate for the patient, items scored as NA (not applicable) are
counted in the measure as a positive, or ‘yes,’ response and the patient will meet the measure criteria. The
patient will either need to meet the criteria for all of the data elements (or have an NA) to pass the measure.

9. Review of EDTC Data Collection Guide Specifications

10. EDTC Excel Data Collection Tool Demo

11. EDTC Data Collection Tool Manual

12. Why this initiative is important to Alaska CAHs
It will provide CAHs the opportunity to collect, analyze, and benchmark the triage and transfer care and communication they provide in their emergency departments.
The measure to be used was developed specifically for CAHs, has been widely tested in rural hospitals, is NQF endorsed, and CAH participation will meet the Phase III MBQIP data collection requirement for the ED Transfer Communication Measure.
Alaska Flex and ASHNHA, will provide data collection training and technical assistance as well as support for interpretation of data reports and development of an action plan to address opportunities for improvement identified by review of CAH results on the measure.
Assess how well patient information is communicated from ED to other health care facilities • Helps EDs provide patients with time-sensitive care that includes transfer to a tertiary care center effectively • The ability to assess, arrange and transport the patient out the door with the necessary and appropriate information can be of life or death importance

13. Recruitment Message
Critical Access Hospitals are increasingly in the spotlight of federal policy makers.  It is more important now than ever to participate in efforts that help demonstrate the quality and value that CAHs provide to rural residents.
Improved transitions of care is a key component of increasing the quality, effectiveness, and efficiency of health care services.  Effective transfer of patient information from the Emergency Department to the next site of care can to foster continuity of patient care and help to reduce errors, improve outcomes, and increase patient and family satisfaction.
Stabilization and transfer of patients in emergency situations is a fundamental role of Critical Access Hospitals in the health care safety net for rural communities.  This project allows CAHs to evaluate and improve the effectiveness of that important role.

14. Reporting Process & Deadlines
Reporting is done quarterly. Data is entered into the EDTC Excel Tool. A quarterly report can be run/generated, which is then to be ed directly to your state Flex Coordinator.
Shellie Smith –
Deadlines
October-December 2016 data (Q4 2016) due January 31st 2017
January-March 2017 data (Q1 2017) due April
April-June 2017 (Q2 2017) due July
July-September 2017 (Q3 2017) due October

15. How We Can Help! You’ll receive:
Focused technical assistance and the use of data submission software and other programs to submit quality data
Training on the Emergency Department Transfer Communication (EDTC) quality reporting program as part of MBQIP
Data that will aide towards improvement
Tools and other resources

16. THANK YOU! Questions ? ? ?
Shanelle Van Dyke
Shellie Smith
Health Program Manager - State of Alaska
Health Planning and Systems Development
Anchorage, AK  99503
Patricia Atkinson
Director of Quality and Performance Improvement
Alaska State Hospital and Nursing Home Association (ASHNHA)
Juneau, AK  99801
(office)