Abstract: Care coordination is a vital aspect of health and healthcare services. When care is poorly coordinated—with inaccurate transmission of information, inadequate communication, and inappropriate follow-up care—patients who see multiple physicians and care providers can face medication errors, hospital readmissions, and avoidable emergency department visits. The effects of poorly coordinated care are particularly evident for people with chronic conditions, such as diabetes and hypertension, and those at high risk for multiple illnesses who often are expected to navigate a complex healthcare system. In this report, NQF has endorsed a portfolio of care coordination preferred practices and performance measures. These standards will provide the structure, process, and outcome measures required to assess progress toward care coordination goals and to evaluate access, continuity, communication, and tracking of patients across providers and settings. Given the high-risk nature of transitions in care, this work will build on ongoing efforts among the medical and surgical specialty societies to establish principles for effective patient hand-offs among clinicians and providers. Measurement and improvement efforts will be upgraded over time as interoperable health information technology (HIT) systems evolve.

August 7, 2019

NQF: Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination

Abstract: Care coordination is a vital aspect of health and healthcare services. When care is poorly coordinated—with inaccurate transmission of information, inadequate communication, and inappropriate follow-up care—patients who see multiple physicians and care providers can face medication errors, hospital readmissions, and avoidable emergency department visits. The effects of poorly coordinated […]
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Abstract: Care coordination is a vital aspect of health and healthcare services. When care is poorly coordinated—with inaccurate transmission of information, inadequate communication, and inappropriate follow-up care—patients who see multiple physicians and care providers can face medication errors, hospital readmissions, and avoidable emergency department visits. The effects of poorly coordinated care are particularly evident for people with chronic conditions, such as diabetes and hypertension, and those at high risk for multiple illnesses who often are expected to navigate a complex healthcare system. In this report, NQF has endorsed a portfolio of care coordination preferred practices and performance measures. These standards will provide the structure, process, and outcome measures required to assess progress toward care coordination goals and to evaluate access, continuity, communication, and tracking of patients across providers and settings. Given the high-risk nature of transitions in care, this work will build on ongoing efforts among the medical and surgical specialty societies to establish principles for effective patient hand-offs among clinicians and providers. Measurement and improvement efforts will be upgraded over time as interoperable health information technology (HIT) systems evolve.
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http://www.qualityforum.org/Publications/2010/10/Preferred_Practices_and_Performance_Measures_for_Measuring_and_Reporting_Care_Coordination.aspx

August 7, 2019

Transitions of Care Consensus Policy Statement

Abstract: The American College of Physicians, Society of Hospital Medicine, and Society of General Internal Medicine convened a multi-stakeholder consensus conference in July 2007 to address the quality gaps in the transitions between inpatient and outpatient settings and to develop consensus standards for these transitions. Over 30 organizations sent representatives […]
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Abstract: The American College of Physicians, Society of Hospital Medicine, and Society of General Internal Medicine convened a multi-stakeholder consensus conference in July 2007 to address the quality gaps in the transitions between inpatient and outpatient settings and to develop consensus standards for these transitions. Over 30 organizations sent representatives to the Transitions of Care Consensus Conference. Participating organizations included medical specialty societies from internal medicine as well as family medicine and pediatrics, governmental agencies such as the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services, performance measure developers such as the National Committee for Quality Assurance and the American Medical Association Physician Consortium on Performance Improvement, nurse associations such as the Visiting Nurse Associations of America and Home Care and Hospice, pharmacist groups, and patient groups such as the Institute for Family-Centered Care. The Transitions of Care Consensus Conference made recommendations for standards concerning the transitions between inpatient and outpatient settings for future implementation. The American College of Physicians, Society of Hospital Medicine, Society of General Internal Medicine, American Geriatric Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine all endorsed this document. Journal of Hospital Medicine 2009;4:364–370. © 2009 Society of Hospital Medicine.
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http://onlinelibrary.wiley.com/doi/10.1002/jhm.510/abstract

August 7, 2019

The Remington Report: Improving Outcomes Through Re-Engineered Care Transitions: The New York Experience

The Centers for Medicare & Medicaid Services (CMS) is funding an initiative with 14 state-based Quality Improvement Organizations (QIOs) to test a variety of interventions and approaches to improving the quality of care for Medicare beneficiaries as they transition from one setting to another. A primary objective of the Care […]
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The Centers for Medicare & Medicaid Services (CMS) is funding an initiative with 14 state-based Quality Improvement Organizations (QIOs) to test a variety of interventions and approaches to improving the quality of care for Medicare beneficiaries as they transition from one setting to another. A primary objective of the Care Transitions Theme is to reduce unnecessary hospital readmissions and the resultant morbidity, mortality and quality of life issues. The project began in August 2008 and will continue through July 2011. The structure of this CMS initiative provides QIOs the flexibility to develop approaches tailored to local needs, while using evidence-based interventions to target improvement across settings.
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http://www.cfmc.org/integratingcare/files/rem_mj10-care_transitions.pdf

August 7, 2019

Transforming Care at the Bedside How-to Guide: Creating an Ideal Transition Home for Patients with Heart Failure

Nielsen GA, Bartely A, Coleman E, Resar R, Rutherford P, Souw D, Taylor J. Transforming Care at the Bedside How-to Guide: Creating an Ideal Transition Home for Patients with Heart Failure. Cambridge, MA: Institute for Healthcare Improvement; http://www.ihi.org/resources/Pages/Tools/TCABHowToGuideTransitionHomeforHF.aspx. 2008. Accessed August 7, 2014. Institute for Healthcare Improvement (in collaboration with […]
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Nielsen GA, Bartely A, Coleman E, Resar R, Rutherford P, Souw D, Taylor J. Transforming Care at the Bedside How-to Guide: Creating an Ideal Transition Home for Patients with Heart Failure. Cambridge, MA: Institute for Healthcare Improvement; http://www.ihi.org/resources/Pages/Tools/TCABHowToGuideTransitionHomeforHF.aspx. 2008. Accessed August 7, 2014. Institute for Healthcare Improvement (in collaboration with the Robert Wood Johnson Foundation) Cambridge, Massachusetts, USA Launched in 2003, Transforming Care at the Bedside (TCAB) is a national program of the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement (IHI). One of the most promising changes that has been developed within TCAB is “creating an ideal transition home” for patients who are being discharged from medical and surgical units within hospitals. This How-to Guide builds upon relevant research and published literature, and integrates what TCAB hospitals have learned as they strive to dramatically improve the quality of care for patients discharged from the hospital to home or to another health care facility.
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http://www.ihi.org/resources/Pages/Tools/TCABHowToGuideTransitionHomeforHF.aspx

August 7, 2019

Assessing the quality of preparation for posthospital care from the patient’s perspective: the care transitions measure

Coleman EA, Mahoney E, Parry C. Assessing the quality of preparation for posthospital care from the patient’s perspective: the care transitions measure. Med Care. 2005 Mar;43(3):246-55. http://www.ncbi.nlm.nih.gov/pubmed/15725981. Accessed August 13, 2014. BACKGROUND: Evidence that both quality and patient safety are jeopardized for patients undergoing transitions across care settings continues to […]
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Coleman EA, Mahoney E, Parry C. Assessing the quality of preparation for posthospital care from the patient's perspective: the care transitions measure. Med Care. 2005 Mar;43(3):246-55. http://www.ncbi.nlm.nih.gov/pubmed/15725981. Accessed August 13, 2014. BACKGROUND: Evidence that both quality and patient safety are jeopardized for patients undergoing transitions across care settings continues to expand. Performance measurement is one potential strategy towards improving the quality of transitional care. A valid and reliable self-report measure of the quality of care transitions is needed that is both consistent with the concept of patient-centeredness and useful for the purpose of performance measurement and quality improvement.
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http://www.ncbi.nlm.nih.gov/pubmed/15725981

August 7, 2019

St. Luke’s Hospital: Where Patients’ Home Care Needs Are Anticipated at Discharge

Institute for Healthcare Improvement. Improvement Stories. 2008. http://www.ihi.org/resources/Pages/ImprovementStories/StLukesHomeCareNeedsAnticipatedatDischarge.aspx. Accessed 8/13/14. For some patients, being discharged from the hospital is a mixed blessing. It can feel both great and scary to return home, especially for those who need to take on new and potentially confusing responsibilities for self-care. At St. Luke’s […]
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Institute for Healthcare Improvement. Improvement Stories. 2008. http://www.ihi.org/resources/Pages/ImprovementStories/StLukesHomeCareNeedsAnticipatedatDischarge.aspx. Accessed 8/13/14. For some patients, being discharged from the hospital is a mixed blessing. It can feel both great and scary to return home, especially for those who need to take on new and potentially confusing responsibilities for self-care. At St. Luke’s Hospital in Cedar Rapids, Iowa, part of the Iowa Health System, a program called Transitions Home is addressing these concerns for patients with heart failure. By providing self-management support for patients at home, the hospital is reducing its rate of readmissions for heart failure patients. The program includes a combination of patient-friendly written information along with a home visit from a nurse, a physician office visit, and follow-up telephone calls. There are also weekend classes on heart failure management and diet, designed to anticipate patients’ need for ongoing reinforcement and support.
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http://www.ihi.org/knowledge/Pages/ImprovementStories/StLukesHomeCareNeedsAnticipatedatDischarge.aspx

August 7, 2019

IHI Collaborative: Hospital to home, Optimizing the Transition

IHI has found that a comprehensive and reliable discharge plan, along with post discharge support, can reduce readmission rates, improve health outcomes and assure quality transitions. The goal of this Web&ACTION is to work with teams to optimize communications, support and involve patients and families, and eliminate waste and improve […]
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IHI has found that a comprehensive and reliable discharge plan, along with post discharge support, can reduce readmission rates, improve health outcomes and assure quality transitions. The goal of this Web&ACTION is to work with teams to optimize communications, support and involve patients and families, and eliminate waste and improve workflow using ideas that have been tested on the discharges of patients with heart failure (HF) on medical-surgical units. Upon completion of this Web&ACTION, participants will be able to: • Reduce unplanned admissions for patients with heart failure • Understand and collect key data regarding hospital readmissions • Describe and test top ideas for reducing heart failure readmissions to hospitals • Increase patient involvement in their care while in the hospital and after discharge
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http://www.ihi.org/knowledge/Pages/Tools/TCABHowToGuideTransitionHomeforHF.aspx

August 7, 2019

Geriatric Resources for Assessment and Care of Elders (GRACE): A New Model of Primary Care for Low-Income Seniors. J Am Geriatr Soc. 2006;54(7):1136-1141.

The majority of older adults receive health care in primary care settings, yet many fail to receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes. The Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care for low-income seniors and their […]
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The majority of older adults receive health care in primary care settings, yet many fail to receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes. The Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care for low-income seniors and their primary care physicians (PCPs) was developed to improve the quality of geriatric care so as to optimize health and functional status, decrease excess healthcare use, and prevent long-term nursing home placement. The catalyst for the GRACE intervention is the GRACE support team, consisting of a nurse practitioner and a social worker. Upon enrollment, the GRACE support team meets with the patient in the home to conduct an initial comprehensive geriatric assessment. The support team then meets with the larger GRACE interdisciplinary team (including a geriatrician, pharmacist, physical therapist, mental health social worker, and community-based services liaison) to develop an individualized care plan including activation of GRACE protocols for evaluating and managing common geriatric conditions. The GRACE support team then meets with the patient's PCP to discuss and modify the plan. Collaborating with the PCP, and consistent with the patient's goals, the support team then implements the plan. With the support of an electronic medical record and longitudinal tracking system, the GRACE support team provides ongoing care management and coordination of care across multiple geriatric syndromes, providers, and sites of care. The effectiveness of the GRACE intervention is being evaluated in a randomized, controlled trial.
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http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2006.00791.x/abstract

August 7, 2019

Team-Developed Care Plan and Ongoing Care Management by Social Workers and Nurse Practitioners Result in Better Outcomes and Fewer Emergency Department Visits for Low-Income Seniors

Social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for low-income seniors. The social worker/nurse team also proactively manages and coordinates the patient’s care on an ongoing basis through regular telephone and in-person contact with both patients and […]
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Social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for low-income seniors. The social worker/nurse team also proactively manages and coordinates the patient's care on an ongoing basis through regular telephone and in-person contact with both patients and providers. The program, known as Geriatric Resources for Assessment and Care of Elders (GRACE), improved the provision of evidence-based care; led to significant improvements in measures of general health, vitality, social functioning, and mental health; reduced emergency department visits and hospital admissions; and generated high levels of physician and patient satisfaction. A recent analysis found that the program was cost neutral for high-risk patients in the first 2 years, and yielded savings by year three. Strong: The evidence consists of a randomized controlled trial (RCT) of 951 patients that compared results for program participants with patients receiving usual care on a variety of metrics (including functional status, activity of daily living status, ED and hospital use, and patient and physician satisfaction).
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http://www.innovations.ahrq.gov/content.aspx?id=2066

August 7, 2019

Groups Focus On Cutting Hospital Readmission Of Medicare Patients

Medicare Quality Improvement Organizations (QIOs) in the states began work last year on the three-year projects aimed at improving readmission rates. These organizations are the Alabama Quality Assurance Foundation, the Louisiana Health Care Review and the Georgia Medical Care Foundation. These QIOs are independent organizations that contract with CMS to […]
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Medicare Quality Improvement Organizations (QIOs) in the states began work last year on the three-year projects aimed at improving readmission rates. These organizations are the Alabama Quality Assurance Foundation, the Louisiana Health Care Review and the Georgia Medical Care Foundation. These QIOs are independent organizations that contract with CMS to improve care. They are examining hospital and community systemwide interventions, interventions that target specific diseases or conditions and interventions that target specific reasons for admission.
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http://www.eqhealthsolutions.com/LinkClick.aspx?fileticket=rJj5n1tRPXw%3D&tabid=99