1. 1 Measuring What Matters: Care Transitions Karen Adams, PhD Senior Program Officer National Quality Forum February 4, 2008

2. 2 History & Background Established in 1999 Non-profit Multi-stakeholder membership organization Voluntary, consensus standard setting organization

3. 3 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

4. 4 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.

5. 5 Priority Setting Pilot Project Kevin Weiss, MD Co-chairElliott Fisher, MD Co-chair

6. 6 Priority Setting Pilot 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

7. 7 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

8. 8 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

9. 9 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

10. 10 Context for Considering an AMI Episode Post Acute/ Rehabilitation Phase 2 0 Prevention Episode begins – onset of symptoms Post AMI Trajectory 2 (T2) Adult with multiple co-morbidities Focus on: Quality of Life Functional Status 2 0 Prevention Strategies Advanced Care Planning Advanced Directives Palliative Care/Symptom Control Assessment of Preferences Acute Phase PHASE 1 PHASE 2 PHASE 3 PHASE 4 Episode ends – 1 year post AMI 2 0 Prevention (CAD with prior AMI) Advanced Care Planning Population at Risk 1 0 Prevention (no known CAD) 2 0 Prevention (CAD no prior AMI) Post AMI Trajectory 1 (T1) Relatively healthy adult Focus on: Quality of Life Functional Status 2 0 Prevention Strategies Rehabilitation Advanced care planning

11. 11 Context for Considering a Low Back Pain Episode 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 Medical Treatment Episode ends – 1 year Patient baseline assessment of function, mental health & comorbidities PHASE 1 PHASE 2 PHASE 4PHASE 5 PHASE 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

12. 12 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.

13. 13 C are 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

14. 14 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)

15. 15 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

16. 16 Not everything that counts can be counted, and not everything that can be counted counts. Albert Einstein

17. 17 Questions/Comments kadams@qualityforum.org