White Paper

West Virginia Medical Institute. Home Health Quality Improvement. Best Practice Intervention Package. Fundamentals of Reducing Acute Care Hospitalization. http://www.avoidreadmissions.com/wwwroot/userfiles/documents/281/bpip-full-content-package.pdf. Published January 2010. Accessed July 25, 2014. Why is the Home Health Quality Improvement (HHQI) National Campaign so Important? It is a grassroots, cross-setting, patient-centered movement with stakeholders, designed to improve the quality of care home health patients receive. A special project funded by Centers for Medicare & Medicaid Services (CMS).

August 8, 2019

Home Health Quality Improvement. Best Practice Intervention Package. Fundamentals of Reducing Acute Care Hospitalization.

West Virginia Medical Institute. Home Health Quality Improvement. Best Practice Intervention Package. Fundamentals of Reducing Acute Care Hospitalization. http://www.avoidreadmissions.com/wwwroot/userfiles/documents/281/bpip-full-content-package.pdf. Published January 2010. Accessed July 25, 2014. Why is the Home Health Quality Improvement (HHQI) National Campaign so Important? It is a grassroots, cross-setting, patient-centered movement with stakeholders, designed to improve […]
Read More
West Virginia Medical Institute. Home Health Quality Improvement. Best Practice Intervention Package. Fundamentals of Reducing Acute Care Hospitalization. http://www.avoidreadmissions.com/wwwroot/userfiles/documents/281/bpip-full-content-package.pdf. Published January 2010. Accessed July 25, 2014. Why is the Home Health Quality Improvement (HHQI) National Campaign so Important? It is a grassroots, cross-setting, patient-centered movement with stakeholders, designed to improve the quality of care home health patients receive. A special project funded by Centers for Medicare & Medicaid Services (CMS).
Read Less
http://www.avoidreadmissions.com/wwwroot/userfiles/documents/281/bpip-full-content-package.pdf

August 8, 2019

Transitions of Care Performance Measures: Paper by the NTOCC Measures Work Group, 2008

The NTOCC Measures Work Group. Transitions of Care Measures. http://www.ntocc.org/Portals/0/PDF/Resources/TransitionsOfCare_Measures.pdf. 2008. Accessed July 24, 2014. The Case Management Society of America (CMSA) convenes the National Transitions of Care Coalition (NTOCC) to develop recommendations on actions that all participants in the health care delivery system can take to improve the quality […]
Read More
The NTOCC Measures Work Group. Transitions of Care Measures. http://www.ntocc.org/Portals/0/PDF/Resources/TransitionsOfCare_Measures.pdf. 2008. Accessed July 24, 2014. The Case Management Society of America (CMSA) convenes the National Transitions of Care Coalition (NTOCC) to develop recommendations on actions that all participants in the health care delivery system can take to improve the quality of care transitions. The multi-disciplinary members of NTOCC work collaboratively to develop policies, tools, and resources as well as recommend actions and protocols to guide and support providers and patients in achieving safe and effective transitions of care.
Read Less
http://www.ntocc.org/Portals/0/TransitionsOfCare_Measures.pdf

August 8, 2019

Improving Transitions of Care: The Vision of the National Transitions of Care Coalition

The National Transitions of Care Coalition. Improving Transitions of Care: The Vision of the National Transitions of Care Coalition. http://www.ntocc.org/Portals/0/PDF/Resources/PolicyPaper.pdf. May 2008. Accessed July 24, 2014. This paper outlines the vision of the National Transitions of Care Coalition (NTOCC) to improve transitions of care, increasing quality of care and patient […]
Read More
The National Transitions of Care Coalition. Improving Transitions of Care: The Vision of the National Transitions of Care Coalition. http://www.ntocc.org/Portals/0/PDF/Resources/PolicyPaper.pdf. May 2008. Accessed July 24, 2014. This paper outlines the vision of the National Transitions of Care Coalition (NTOCC) to improve transitions of care, increasing quality of care and patient safety while controlling costs.
Read Less
http://www.ntocc.org/Portals/0/PolicyPaper.pdf

August 8, 2019

Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Model. Version 2

American Pharmacists Association and the National Association of Chain Drug Stores Foundation. Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Model. Version 2. http://www.accp.com/docs/positions/misc/CoreElements.pdf. 2008. Accessed April 26, 2013. Eleven national pharmacy organizations achieved consensus on a definition of medication therapy management (MTM) in July […]
Read More
American Pharmacists Association and the National Association of Chain Drug Stores Foundation. Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Model. Version 2. http://www.accp.com/docs/positions/misc/CoreElements.pdf. 2008. Accessed April 26, 2013. Eleven national pharmacy organizations achieved consensus on a definition of medication therapy management (MTM) in July 2004 (Appendix A). Building on the consensus definition, the American Pharmacists Association and the National Association of Chain Drug Stores Foundation developed a model framework for implementing effective MTM services in a community pharmacy setting by publishing Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Version 1.0. The original version 1.0 document described the foundational or core elements of MTM services that could be provided by pharmacists across the spectrum of community pharmacy. Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model Version 2.0 is an evolutionary document that focuses on the provision of MTM services in settings where patients* or their caregivers can be actively involved in managing their medications. This service model was developed with the input of an advisory panel of pharmacy leaders representing diverse pharmacy practice settings (listed in Addendum). While adoption of this model is voluntary, it is important to note that this model is crafted to maximize both effectiveness and efficiency of MTM service delivery across pharmacy practice settings in an effort to improve continuity of care and patient outcomes. *In this document, the term patient refers to the patient, the caregiver, or other persons involved in the care of the patient.
Read Less
http://www.accp.com/docs/positions/misc/CoreElements.pdf

August 8, 2019

NTOCC Suggested Common/Essential Data Elements for Medication Reconciliation

NTOCC. Suggested Common/Essential Data Elements for Medication Reconciliation. http://www.ntocc.org/Portals/0/PDF/Resources/Medication_Reconciliation.pdf . Published 4/17/08. Accessed 7/9/14. Contains data elements for medication reconciliation assessment on access to care setting and on transfer of care.
NTOCC. Suggested Common/Essential Data Elements for Medication Reconciliation. http://www.ntocc.org/Portals/0/PDF/Resources/Medication_Reconciliation.pdf . Published 4/17/08. Accessed 7/9/14. Contains data elements for medication reconciliation assessment on access to care setting and on transfer of care.
Read Less
http://www.ntocc.org/Portals/0/PDF/Resources/Medication_Reconciliation.pdf

August 8, 2019

Aurora Health Care: How to create an Accurate Medication List in the Outpatient Setting Through a Patient-Centered Approach

Aurora Health Care partnered with Consumers Advancing Patient Safety (CAPS) and Midwest Airlines to implement a patient partnership model as an intervention to improve medication safety in the outpatient setting. Bringing patients and health care providers together with a common goal offered the opportunity for collaboration and insight to the […]
Read More
Aurora Health Care partnered with Consumers Advancing Patient Safety (CAPS) and Midwest Airlines to implement a patient partnership model as an intervention to improve medication safety in the outpatient setting. Bringing patients and health care providers together with a common goal offered the opportunity for collaboration and insight to the needs of our patients.
Read Less
http://www.ahrq.gov/downloads/pub/advances2/vol3/advances-leonhardt_35.pdf

August 8, 2019

The Evaluation of the Medicare Coordinated Care Demonstration Findings for the First Two Years

Brown R, Peikes D, Chen A, et al. Mathematica Policy Research, Inc. The Evaluation of the Medicare Coordinated Care Demonstration: Findings for the First Two Years. http://www.mathematica-mpr.com/~/media/publications/PDFs/mccdfirsttwoyrs.pdf. Published March 21, 2007. Accessed December 11, 2014. This report synthesizes findings from the first 2 years of the demonstration programs operations, focusing […]
Read More
Brown R, Peikes D, Chen A, et al. Mathematica Policy Research, Inc. The Evaluation of the Medicare Coordinated Care Demonstration: Findings for the First Two Years. http://www.mathematica-mpr.com/~/media/publications/PDFs/mccdfirsttwoyrs.pdf. Published March 21, 2007. Accessed December 11, 2014. This report synthesizes findings from the first 2 years of the demonstration programs operations, focusing on program impacts over the first year after enrollment for beneficiaries who enrolled during the first year, and over the first 25 months of operations for all enrollees. Findings presented include program-specific estimates of impacts on (1) survey-based measures of patients. health status, knowledge, behavior, satisfaction with their health care, quality of care, and quality of life; and (2) claims-based measures of patients. Medicare service use and expenditures, and the quality of care received. The report links differences across programs in these impacts to differences in the interventions and the target populations in order to draw inferences about .what works. and .for whom.. This synthesis of findings draws on an earlier report to Congress that described the types of programs and beneficiaries participating in the demonstrations, the interventions the programs have implemented, and how well patients and physicians like the programs (Brown et al. 2004). This report updates that information and adds analyses of Medicare service use and expenditures and a scoring methodology developed specifically for this evaluation to rate the quality of each program’s intervention on several dimensions. The findings in brief indicate that patients and physicians were generally very satisfied with the program, but few programs had statistically detectable effects on patients. behavior or use of Medicare services. Treating only statistically significant treatment-control differences as evidence of program effects, the results show: • Few effects on beneficiaries. overall satisfaction with care • An increase in the percentage of beneficiaries reporting they received health education • No clear effects on patients. adherence or self-care • Favorable effects for only two programs each on: the quality of preventive care, the number of preventable hospitalizations, and patients. well-being • A small but statistically significant reduction (about 2 percentage points) across all programs combined in the proportion of patients hospitalized during the year after enrollment • Reduced number of hospitalizations for only 1 of the 15 programs over the first 25 months of program operations • No reduction in expenditures for Medicare Part A and B services for any program
Read Less
http://www.mathematica-mpr.com/publications/pdfs/mccdfirsttwoyrs.pdf

August 7, 2019

Care Coordination for People with Chronic Conditions

A literature review found many variations among organizations providing care coordination for people with chronic conditions. While this paper includes some description of the development of care coordination in health plans, it is primarily focused on state initiatives involving public programs such as Medicaid.
A literature review found many variations among organizations providing care coordination for people with chronic conditions. While this paper includes some description of the development of care coordination in health plans, it is primarily focused on state initiatives involving public programs such as Medicaid.
Read Less
http://www.partnershipforsolutions.org/DMS/files/Care_coordination.pdf

August 7, 2019

Coordination of Care for Persons With Disabilities Enrolled in Medicaid Managed Care Plans

The purpose of this document is to present a conceptual framework to guide the development of measures of care coordination that would be both feasible to apply and meaningful in assessing the performance of Medicaid managed care organizations (MCOs) that enroll people with disabilities. Although there are no explicitly required […]
Read More
The purpose of this document is to present a conceptual framework to guide the development of measures of care coordination that would be both feasible to apply and meaningful in assessing the performance of Medicaid managed care organizations (MCOs) that enroll people with disabilities. Although there are no explicitly required care coordination systems now in place, some states are providing systems of coordination and doing it with existing resources. This document presents a structure for defining and measuring good care coordination for states that have systems and want to measure them, and for those who may wish to implement systems in the future.
Read Less
http://aspe.hhs.gov/daltcp/reports/carecoor.pdf

August 7, 2019

Health Care Leader Action Guide to Reduce Avoidable Readmissions

Reducing avoidable hospital readmissions is an opportunity to improve quality and reduce costs in the health care system. This guide is designed to serve as a starting point for hospital leaders to assess, prioritize, implement, and monitor strategies to reduce avoidable readmissions.
Reducing avoidable hospital readmissions is an opportunity to improve quality and reduce costs in the health care system. This guide is designed to serve as a starting point for hospital leaders to assess, prioritize, implement, and monitor strategies to reduce avoidable readmissions.
Read Less
http://www.commonwealthfund.org/Publications/Fund-Manuals/2010/Jan/Health-Care-Leader-Action-Guide.aspx