Measuring What Matters:
Care Transitions
Karen Adams, PhD
Senior Program Officer
National Quality Forum
February 4, 2008
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History & Background
• Established in 1999
• Non-profit
• Multi-stakeholder membership
organization
• Voluntary, consensus standard setting
organization
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National Technology Transfer
and Advancement Act of 1995
• Defines 5 attributes of a voluntary consensus
standards setting body
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–
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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
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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.
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Priority Setting
Pilot Project
Kevin Weiss, MD Co-chair
Elliott Fisher, MD Co-chair
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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
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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
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Framework Domains:
Measuring What Matters
• Patient-level outcomes
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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
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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
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Context for Considering an AMI Episode
Post AMI Trajectory 1 (T1)
Relatively healthy adult
Assessment of
Preferences
Focus on:
• Quality of Life
• Functional Status
• 20 Prevention Strategies
• Rehabilitation
• Advanced care planning
Population at Risk
10 Prevention
(no known CAD)
20 Prevention
(CAD no prior AMI)
Acute
Phase
Post Acute/
Rehabilitation
Phase
PHASE 2
PHASE 3
20 Prevention
20 Prevention
(CAD with prior AMI)
Advanced Care Planning
PHASE 4
PHASE 1
Staying Healthy
Getting Better
Episode begins –
onset of symptoms
Living w/ Illness/Disability (T1)
Coping w/ End of Life (T2)
Post AMI Trajectory 2 (T2)
Adult with multiple co-morbidities
Focus on:
• Quality of Life
• Functional Status
• 20 Prevention Strategies
• Advanced Care Planning
• Advanced Directives
• Palliative Care/Symptom Control
Episode ends –
1 year post AMI
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Context for Considering a
Low Back Pain Episode
Trajectory 1 (T1)
Returning back to work &
assuming normal activities
of daily living
Confirm back pain
syndrome; Rule out red flags
(i.e. malignancy, infection)
Focus on:
• Quality of Life
• Functional Status
• Patient-generated goals
• Education & prevention
of future episodes
Population at Risk
Adults with back pain
Diagnosis &
Initial
Management
Shared Decision
Making &
Informed Choice
PHASE 3
Surgery or
Medical
Treatment
PHASE 4
Follow-up
Care &
Prevention
PHASE 5
PHASE 2
Trajectory 2 (T2)
Patient at risk for longterm chronic disability
PHASE 1
Patient baseline
assessment of function,
mental health &
comorbidities
Focus on:
• Quality of Life
• Functional Status
• Patient-generated goals
Staying Healthy (T1)
Getting Better
Episode begins –
onset of symptoms
Living w/
Illness/Disability (T2)
Episode ends –
1 year
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NQF Endorsed Care
Transition Measure
• Care Transitions Measure: CTM-3
 Developed by Eric Coleman
 Include 3 patient questions answered on a 5point 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.
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Care Coordination
Framework
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NQF endorsed Care Coordination Framework
has five key dimensions:
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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
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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)
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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
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Not everything that counts can be
counted, and not everything that can be
counted counts.
Albert Einstein
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Questions/Comments
kadams@qualityforum.org
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