1. health and fitness

Safe Transitions
Best Practice Measures
for
Emergency Departments
Setting-specific process measures focused on
cross-setting communication and patient activation,
supporting safe patient care across the continuum
This material was prepared by the New England Quality Innovation Network-Quality Improvement Organization
(NE QIN-QIO), the Medicare Quality Improvement Organization for New England, under contract with the Centers
for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The
contents presented do not necessarily reflect CMS policy. CMSQIN_C3-1_201505_0039
Safe Transitions Best Practice Measures
MEASURE SET: Safe transitions best practice measures for emergency departments (EDs) MEASURES: The best practice measures for EDs are eight (8) process measures: 1.
2.
3.
4.
5.
6.
7.
8.
Documentation of patients’ primary care provider Documentation of patients’ home care provider Summary clinical information provided to primary care provider upon ED discharge Summary clinical information provided to home care provider upon ED discharge Summary clinical information provided to receiving provider upon ED discharge or transfer to another facility Medication reconciliation completed prior to discharge Effective education provided to patients prior to discharge Written discharge instructions provided to patients prior to discharge PURPOSE: The best practice measures are intended to improve provider‐to‐provider communication and patient activation during patient transitions between any two settings. EDs can use these measures to evaluate performance and implement targeted improvement to: 1) improve partnerships with inpatient and outpatient providers, 2) improve patient experience, and/or 3) reduce unplanned utilization. Some of these processes are adapted from interventions proven to improve care transitions outcomes, such as hospital readmission, in the medical literature. Others are based on national campaigns and standards. POPULATION: Varies by measure, but generally includes patients currently being seen or recently discharged from the ED CARE SETTING: Emergency department RECIPROCAL MEASURES: In addition to the best practices for EDs, Healthcentric Advisors developed five (5) additional sets of setting‐specific measures, for: 1.
2.
3.
4.
5.
Community physician offices Home health agencies Hospitals Nursing homes Urgent care centers NOTES: Because these measures are intended to set minimum standards for all patients, no sampling guidelines are provided. Providers who cannot calculate the measures electronically may wish to implement a representative sampling frame to calculate performance on an ongoing basis. Providers may also wish to implement small‐scale pilots to measure baseline performance and implement targeted improvement strategies before expanding efforts facility wide. For those seeking assistance, Healthcentric Advisors provides consultative services related to quality improvement, measurement and care transitions. 1
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org Safe Transitions Best Practice Measures
MEASURE SET HISTORY: These measures were developed by Healthcentric Advisors, the Medicare Quality Improvement Organization for Rhode Island, using a multi‐stage stakeholder consensus process. The measures have since been updated. This process involved: 1) reviewing the medical literature (where it exists) and national campaigns and standards, 2) collecting input about community preferences, 3) drafting measures, and 4) and obtaining input (measure content and feasibility) and endorsement from the targeted provider group (EDs) and their partners (e.g., primary care providers and urgent care centers) and stakeholders (e.g., state agencies and payors). This quality improvement process was deemed exempt by the Rhode Island Department of Health’s Institutional Review Board. As a quality improvement project that incorporated local preference, these measures may not be generalizable to other states and regions, but can inform the development of local standards. MEASURE INFORMATION: CONSULTING SERVICES: Lynne Chase Senior Program Administrator, Healthcentric Advisors [email protected] or 401.528.3253 Kara Butler, MBA, MHA Senior Manager, Corporate Services, Healthcentric Advisors
[email protected] or 401.528.3221 LAST UPDATED: 02 Oct 2013 2
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org Safe Transitions Best Practice Measures
MEASURE: Documentation of patients’ primary care provider MEASURE SET: Safe transitions best practice measures for emergency departments (Best Practice #1) MEASURE DESCRIPTION: This measure estimates the frequency with which emergency departments (EDs) ask patients for the name of their primary care provider. Asking for the name of the patient’s primary care provider is the first step towards bi‐directional communication of questions and clinical information. Timely and adequate information transfer is an important component of safe patient transitions between care settings and has been linked to improved patient experience and outcomes.1 Community‐based primary care providers indicate that they are often unaware of their patients’ ED utilization and want to be notified at patient intake. If aware of patients’ arrival in the ED, primary care providers could help to prevent unnecessary healthcare utilization (e.g., duplicate testing or hospital admission). NUMERATOR: Documentation of one of the following:  The name of the patient’s primary care provider,  The fact that the patient does not have a primary care provider, or  The fact that the patient is unsure of their primary care provider’s name or otherwise unable to answer. DENOMINATOR: All patients seen in the emergency department EXCLUSIONS: None RISK ADJUSTMENT: None DEFINITIONS Primary care provider: The clinician identified by the patient as their usual source of care or regular physician or the primary care provider designated in the medical record. For long‐stay nursing home residents, this is the long‐term care physician. For short‐stay skilled nursing patients, who will resume care with their primary care provider upon skilled nursing facility discharge, this is the community‐based primary care provider. NOTES: If patients do not have a primary care provider, are unsure of their primary care provider’s name or are otherwise unable to answer, this should be noted in the medical record instead (i.e., do not leave the field blank). The best practice is for the emergency department to ask this question with every patient, at every visit, since this information is subject to change over time. 3
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org Safe Transitions Best Practice Measures
CLASSIFICATION: National Quality Strategy Priorities: Actual or Planned Use: Care Setting: Patient Condition: Data Source: Level of Analysis: Measure Type: Target Population: Promoting effective communication and coordination of care Quality improvement with benchmarking; contracting; pay for performance Emergency department Not applicable – all patients Medical record or electronic audit trail Practitioner, department or community (e.g., health system or state) Process measure All patients in the emergency department MEASURE HISTORY: These measures were developed by Healthcentric Advisors, the Medicare Quality Improvement Organization for Rhode Island, using a multi‐stage stakeholder consensus process. The measures have since been updated. This process involved: 1) reviewing the medical literature (where it exists) and national campaigns and standards, 2) collecting input about community preferences, 3) drafting measures, and 4) and obtaining input (measure content and feasibility) and endorsement from the targeted provider group (EDs) and their partners (e.g., primary care providers and urgent care centers) and stakeholders (e.g., state agencies and payors). This quality improvement process was deemed exempt by the Rhode Island Department of Health’s Institutional Review Board. As a quality improvement project that incorporated local preference, these measures may not be generalizable to other states and regions, but can inform the development of local standards. MEASURE INFORMATION: CONSULTING SERVICES: Lynne Chase Senior Program Administrator, Healthcentric Advisors [email protected] or 401.528.3253 Kara Butler, MBA, MHA Senior Manager, Corporate Services, Healthcentric Advisors
[email protected] or 401.528.3221 MEASURE DEVELOPED: 2009 MEASURE LAST UPDATED: 23 September 2013 1
Snow V, Beck D, Budnitz T, Miller DC, Potter J, Wears RL, et al. Transitions of Care Consensus Policy Statement American College of Physicians‐Society of General Internal Medicine‐Society of Hospital Medicine‐American Geriatrics Society‐American College of Emergency Physicians‐Society of Academic Emergency Medicine. J Gen Intern Med. 2009; 24(8):971‐6. 4
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org Safe Transitions Best Practice Measures
MEASURE: Documentation of patients’ home care provider MEASURE SET: Safe transitions best practice measures for emergency departments (Best Practice #2) MEASURE DESCRIPTION: This measure estimates the frequency with which emergency departments (EDs) ask patients for the name of their home care provider. Asking for the name of the patient’s home care provider is the first step towards bi‐directional communication of questions and clinical information. Timely and adequate information transfer is an important component of safe patient transitions between care settings and has been linked to improved patient experience and outcomes.1 Community‐based home care providers may not be aware of their patients’ ED utilization and, if aware, could help to prevent unnecessary healthcare utilization, such as duplicate testing or an inpatient admission. Notification may be particularly important for hospice patients, many of whom have Medicare and therefore no insurance coverage outside the hospice plan of care for their terminal diagnosis. If the hospice agency is aware of the ED visit while the patient is in the ED, they can send a nurse. This can prevent unwanted admissions or diagnostic studies and other interventions, for which patients could be financially responsible. NUMERATOR: Documentation of one of the following:  The name of the patient’s home care provider, if the patient is currently receiving services (i.e., not if they have ever received services in the past),  The fact that the patient does not currently have home care, or  The fact that the patient has home care, but is unsure of their provider’s name or otherwise unable to answer. DENOMINATOR: All patients seen in the emergency department EXCLUSIONS: Patients who come from a skilled nursing or long‐term care facility RISK ADJUSTMENT: None – see exclusions DEFINITIONS Home care provider: Any organization that provides home‐based or community‐based medical, nursing, social or therapeutic treatment to the patient, including home health agencies, hospice, PACE, etc. NOTES: If patients do not currently have home care, are unsure of their provider’s name or are otherwise unable to answer, this should be noted in the medical record instead (i.e., do not leave the field blank). The best practice to ask this question with every patient, at every visit, since this information is subject to change over time. The name of the home care provider should be documented only if the patient is currently receiving services, not if they have ever received services in the past. 5
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org Safe Transitions Best Practice Measures
CLASSIFICATION: National Quality Strategy Priorities: Actual or Planned Use: Care Setting: Patient Condition: Data Source: Level of Analysis: Measure Type: Target Population: Promoting effective communication and coordination of care Quality improvement with benchmarking; contracting; pay for performance Emergency department Not applicable – all patients Medical record or electronic audit trail Practitioner, department or community (e.g., health system or state) Process measure All patients in the emergency department MEASURE HISTORY: These measures were developed by Healthcentric Advisors, the Medicare Quality Improvement Organization for Rhode Island, using a multi‐stage stakeholder consensus process. The measures have since been updated. This process involved: 1) reviewing the medical literature (where it exists) and national campaigns and standards, 2) collecting input about community preferences, 3) drafting measures, and 4) and obtaining input (measure content and feasibility) and endorsement from the targeted provider group (EDs) and their partners (e.g., primary care providers and urgent care centers) and stakeholders (e.g., state agencies and payors). This quality improvement process was deemed exempt by the Rhode Island Department of Health’s Institutional Review Board. As a quality improvement project that incorporated local preference, these measures may not be generalizable to other states and regions, but can inform the development of local standards. MEASURE INFORMATION: CONSULTING SERVICES: Lynne Chase Senior Program Administrator, Healthcentric Advisors [email protected] or 401.528.3253 Kara Butler, MBA, MHA Senior Manager, Corporate Services, Healthcentric Advisors
[email protected] or 401.528.3221 MEASURE DEVELOPED: 2009 MEASURE LAST UPDATED: 23 September 2013 1
Snow V, Beck D, Budnitz T, Miller DC, Potter J, Wears RL, et al. Transitions of Care Consensus Policy Statement American College of Physicians‐Society of General Internal Medicine‐Society of Hospital Medicine‐American Geriatrics Society‐American College of Emergency Physicians‐Society of Academic Emergency Medicine. J Gen Intern Med. 2009; 24(8):971‐6. 6
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org Safe Transitions Best Practice Measures
MEASURE: Summary clinical information provided to primary care provider upon emergency department discharge MEASURE SET: Safe transitions best practice measures for emergency departments (Best Practice #3) MEASURE DESCRIPTION: This measure estimates the frequency with which emergency departments (EDs) provide primary care providers with summary clinical information about their patients’ ED visits. Timely and adequate information transfer is an important component of safe patient transitions between care settings and has been linked to improved patient experience and outcomes.1 Effective transfer of information allows outpatient physicians to immediately assume care of discharged patients without spending time on record requests or repeat testing and without defaulting (in the absence of information) to referring patients back to the ED. Community‐based primary care providers indicate that they are often unaware of their patients’ ED utilization and want to be notified of the visit, even if urgent clinical follow‐up is not warranted for the patient’s complaint. (For example, an ED visit for a sore throat may not require follow‐up, but could provide an opportunity for patient education about where to access appropriate care.)
NUMERATOR: Documentation of the following sent to primary care provider within one (1) hour of patient discharge:  Medical diagnosis,  Updated medication list with reason for any changes,  Results of relevant diagnostic tests and presence of pending tests,  Name of ED clinician and ED contact information,  Discharge instructions, and  Recommended follow‐up. DENOMINATOR: All patients discharged home from the ED EXCLUSIONS: Patients without a known primary care provider RISK ADJUSTMENT: None – see exclusions DEFINITIONS ED contact information: Phone number the primary care provider can call for more information about the ED stay and recommended follow‐up, if needed. Primary care provider: The clinician identified by the patient as their usual source of care or regular doctor or the primary care provider designated in the medical record. Summary clinical information may be sent to a primary care physician, specialist mid‐level practitioner, office location, facility or clinic. Relevant diagnostic tests: Imaging or other tests performed as part of the ED evaluation that, in the ED physician’s judgment, would be useful for the patient’s follow‐up care. EDs can opt to send more information if they feel referring primary care providers want this. 7
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org Safe Transitions Best Practice Measures
Sent: Transmitted from the ED to the primary care provider’s office via fax, email or other electronic means.
NOTES: The information may come from the patient’s discharge paperwork and therefore may be patient‐oriented. The summary clinical information here is the same as the information sent to home care providers as part of Best Practice #4. CLASSIFICATION: National Quality Strategy Priorities: Actual or Planned Use: Care Setting: Patient Condition: Data Source: Level of Analysis: Measure Type: Target Population: Promoting effective communication and coordination of care Quality improvement with benchmarking; contracting; pay for performance Emergency department Not applicable – all patients Medical record or electronic audit trail Practitioner, department or community (e.g., health system or state) Process measure All patients discharged home from the ED MEASURE HISTORY: These measures were developed by Healthcentric Advisors, the Medicare Quality Improvement Organization for Rhode Island, using a multi‐stage stakeholder consensus process. The measures have since been updated. This process involved: 1) reviewing the medical literature (where it exists) and national campaigns and standards, 2) collecting input about community preferences, 3) drafting measures, and 4) and obtaining input (measure content and feasibility) and endorsement from the targeted provider group (EDs) and their partners (e.g., primary care providers and urgent care centers) and stakeholders (e.g., state agencies and payors). This quality improvement process was deemed exempt by the Rhode Island Department of Health’s Institutional Review Board. As a quality improvement project that incorporated local preference, these measures may not be generalizable to other states and regions, but can inform the development of local standards. MEASURE INFORMATION: CONSULTING SERVICES: Lynne Chase Senior Program Administrator, Healthcentric Advisors [email protected] or 401.528.3253 Kara Butler, MBA, MHA Senior Manager, Corporate Services, Healthcentric Advisors
[email protected] or 401.528.3221 MEASURE DEVELOPED: 2009 MEASURE LAST UPDATED: 23 September 2013 1
Snow V, Beck D, Budnitz T, Miller DC, Potter J, Wears RL, et al. Transitions of Care Consensus Policy Statement American College of Physicians‐Society of General Internal Medicine‐Society of Hospital Medicine‐American Geriatrics Society‐American College of Emergency Physicians‐Society of Academic Emergency Medicine. J Gen Intern Med. 2009; 24(8):971‐6. 8
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org Safe Transitions Best Practice Measures
MEASURE: Summary clinical information provided to home care provider upon emergency department discharge MEASURE SET: Safe transitions best practice measures for emergency departments (Best Practice #4) MEASURE DESCRIPTION: This measure estimates the frequency with which emergency departments (EDs) provide home care providers with summary clinical information about their patients’ ED visits. Timely and adequate information transfer is an important component of safe patient transitions between care settings and has been linked to improved patient experience and outcomes.1 Home care providers indicate that they are often unaware of their patients’ ED utilization and want to be notified of the visit, even if clinical follow‐up is not warranted for the patient’s complaint. (For example, an ED visit for a sore throat may not require follow‐up, but could provide an opportunity for patient education about where to access appropriate care.)
Notification may be particularly important for hospice patients, many of whom have Medicare and therefore no insurance coverage outside the hospice plan of care for their terminal diagnosis. If the hospice is aware of the ED visit while the patient is in the emergency department, they can send a nurse. This can prevent unwanted admissions or diagnostic studies and other interventions, for which patients could be financially responsible. NUMERATOR: Documentation of the following sent to home care provider, if applicable, within 1 hour of patient discharge:  Medical diagnosis,  Updated medication list with reason for any changes,  Results of relevant diagnostic tests and presence of pending tests,  Name of ED clinician and ED contact information,  Discharge instructions, and  Recommended follow‐up.
DENOMINATOR: All patients discharged home from the ED who are currently receiving home care services EXCLUSIONS: Patients without a known home care provider RISK ADJUSTMENT: None – see exclusions DEFINITIONS ED contact information: Phone number the primary care provider can call for more information about the ED stay and recommended follow‐up, if needed. Home care provider: Any organization that provides home‐ or community‐based medical, nursing, social or therapeutic treatment to the patient, including home health agencies, hospice, PACE, etc. Relevant diagnostic tests: Imaging or other tests performed as part of the ED evaluation that, in the ED physician’s judgment, would be useful for the patient’s follow‐up care. EDs can opt to send more information if they feel referring home care providers want this. 9
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org Safe Transitions Best Practice Measures
Sent: Transmitted from the ED to the home care provider office via fax, email, or other electronic means. NOTES: Summary clinical information should be sent to the home care provider only if the patient is currently receiving services, not if they have ever received services in the past. The information may come from the patient’s discharge paperwork and therefore may be patient‐oriented. The summary clinical information here is the same as the information sent to primary care physicians as part of Best Practice #3. CLASSIFICATION: National Quality Strategy Priorities: Actual or Planned Use: Care Setting: Patient Condition: Data Source: Level of Analysis: Measure Type: Target Population: Promoting effective communication and coordination of care Quality improvement with benchmarking; contracting; pay for performance Emergency department Not applicable – all patients Medical record or electronic audit trail Practitioner, department or community (e.g., health system or state) Process measure All patients discharged home from the ED who are receiving home care services MEASURE HISTORY: These measures were developed by Healthcentric Advisors, the Medicare Quality Improvement Organization for Rhode Island, using a multi‐stage stakeholder consensus process. The measures have since been updated. This process involved: 1) reviewing the medical literature (where it exists) and national campaigns and standards, 2) collecting input about community preferences, 3) drafting measures, and 4) and obtaining input (measure content and feasibility) and endorsement from the targeted provider group (EDs) and their partners (e.g., primary care providers and urgent care centers) and stakeholders (e.g., state agencies and payors). This quality improvement process was deemed exempt by the Rhode Island Department of Health’s Institutional Review Board. As a quality improvement project that incorporated local preference, these measures may not be generalizable to other states and regions, but can inform the development of local standards. MEASURE INFORMATION: CONSULTING SERVICES: Lynne Chase Senior Program Administrator, Healthcentric Advisors [email protected] or 401.528.3253 Kara Butler, MBA, MHA Senior Manager, Corporate Services, Healthcentric Advisors
[email protected] or 401.528.3221 MEASURE DEVELOPED: 2009 MEASURE LAST UPDATED: 23 September 2013 1
Snow V, Beck D, Budnitz T, Miller DC, Potter J, Wears RL, et al. Transitions of Care Consensus Policy Statement American College of Physicians‐Society of General Internal Medicine‐Society of Hospital Medicine‐American Geriatrics Society‐American College of Emergency Physicians‐Society of Academic Emergency Medicine. J Gen Intern Med. 2009; 24(8):971‐6. 10
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org Safe Transitions Best Practice Measures
MEASURE: Summary clinical information provided to receiving provider upon emergency department discharge or transfer to another facility MEASURE SET: Safe transitions best practice measures for emergency departments (Best Practice #5) MEASURE DESCRIPTION: This measure estimates the frequency with which emergency departments (EDs) provide receiving providers with summary clinical information about patients’ ED visits, when the patient is discharged from the ED to another facility (skilled nursing, long‐term care or acute care). Timely and adequate information transfer is an important component of safe patient transitions between care settings and has been linked to improved patient experience and outcomes.1 Information transfer to the next facility helps receiving or downstream providers prepare for patient intake (if transmitted prior to patient discharge from the ED) and ensure continuity of care. NUMERATOR: Documentation of the following sent to the receiving physician with the patient or within 1 hour of patient discharge:  Medical diagnosis,  Clinical services provided,  Results of relevant diagnostic tests and presence of pending tests,  Name of ED clinician and ED contact information, and  For skilled nursing facility and long‐term care discharges, updated medication list with reason for any changes and recommended follow‐up. DENOMINATOR: Patients:  Discharged to a skilled nursing or long‐term care facility, or  Transferred from the ED to another acute‐care hospital. EXCLUSIONS: None RISK ADJUSTMENT: None DEFINITIONS Clinical services provided: This may include medications dispensed, procedures performed, relevant vitals and physical exam findings, nursing notes, and other events in the ED course that, in the ED physician’s judgment, would be useful for the patient’s care in the receiving facility. ED contact information: Phone number the receiving provider can call for more information about the ED stay and recommended follow‐up, if needed. Receiving provider: The physician, mid‐level practitioner or nurse at the next facility (skilled nursing, long‐term care or acute care) who will immediately be assuming care of the patient after ED discharge or transfer. 11
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org Safe Transitions Best Practice Measures
Relevant diagnostic tests: Sent: Imaging or other tests performed as part of the ED evaluation that, in the ED physician’s judgment, would be useful for the patient’s care in the receiving facility. EDs can opt to send more information if they feel their receiving facilities want this. Transmitted from the ED to the facility via the patient’s transport, fax, email or other electronic means. NOTES: This Best Practice refers to communication with physicians who will be assuming care of a patient in another facility—
not communication with hospital physicians in the same hospital. If patients are coming from a skilled nursing facility, they will resume care with their primary care provider (PCP) upon skilled nursing facility discharge; therefore, it is recommended to send the summary clinical information, not only to the skilled nursing facility, but also to the PCP listed in the medical record. CLASSIFICATION: National Quality Strategy Priorities: Actual or Planned Use: Care Setting: Patient Condition: Data Source: Level of Analysis: Measure Type: Target Population: Promoting effective communication and coordination of care Quality improvement with benchmarking; contracting; pay for performance Emergency department Not applicable – all patients Medical record or electronic audit trail Practitioner, department or community (e.g., health system or state) Process measure All patients in the emergency department who are discharged home or to a skilled nursing or long‐term care facility MEASURE HISTORY: These measures were developed by Healthcentric Advisors, the Medicare Quality Improvement Organization for Rhode Island, using a multi‐stage stakeholder consensus process. The measures have since been updated. This process involved: 1) reviewing the medical literature (where it exists) and national campaigns and standards, 2) collecting input about community preferences, 3) drafting measures, and 4) and obtaining input (measure content and feasibility) and endorsement from the targeted provider group (EDs) and their partners (e.g., primary care providers and urgent care centers) and stakeholders (e.g., state agencies and payors). This quality improvement process was deemed exempt by the Rhode Island Department of Health’s Institutional Review Board. As a quality improvement project that incorporated local preference, these measures may not be generalizable to other states and regions, but can inform the development of local standards. MEASURE INFORMATION: CONSULTING SERVICES: Lynne Chase Senior Program Administrator, Healthcentric Advisors [email protected] or 401.528.3253 Kara Butler, MBA, MHA Senior Manager, Corporate Services, Healthcentric Advisors
[email protected] or 401.528.3221 MEASURE DEVELOPED: 2009 MEASURE LAST UPDATED: 7 October 2013 1
Snow V, Beck D, Budnitz T, Miller DC, Potter J, Wears RL, et al. Transitions of Care Consensus Policy Statement American College of Physicians‐Society of General Internal Medicine‐Society of Hospital Medicine‐American Geriatrics Society‐American College of Emergency Physicians‐Society of Academic Emergency Medicine. J Gen Intern Med. 2009; 24(8):971‐6. 12
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org Safe Transitions Best Practice Measures
MEASURE: Modified medication reconciliation completed prior to discharge MEASURE SET: Safe transitions best practice measures for emergency departments (Best Practice #6) MEASURE DESCRIPTION: This measure estimates the frequency with which patients in the emergency department (ED) receive modified medication reconciliation before they leave the ED. A 2012 systematic review showed that hospital medication reconciliation was associated with decreased risk for adverse drug events.12 Medication reconciliation is a Joint Commission patient safety goal and can help to ensure that: 1) providers identify potential medication errors and 2) patients understand which medications to stop, start or adjust after ED discharge. Recognizing the unique clinical environment in the ED, the Joint Commission has modified the medication reconciliation requirements delineated in their patient safety goals for hospitals.3
NUMERATOR: Documentation of medication reconciliation prior to discharge DENOMINATOR: All patients discharged home or to a skilled nursing or long‐term care facility EXCLUSIONS: Patients transferred from the ED to another acute‐care hospital RISK ADJUSTMENT: None – see exclusions DEFINITIONS Modified medication reconciliation: The process of: 1) identifying which medications the patient should stop, start, or adjust the dose of after the ED visit; and 2) providing both the patient and their providers (e.g., primary care provider and skilled nursing or long‐term care facility) with a written list of medications, along with the reason for any changes. NOTES: A more robust definition of medication reconciliation, used in most other healthcare settings, includes identifying the name, dosage, route and frequency for every medication a patient is currently taking or should be taking. Although this approach is not currently required in the ED by the Joint Commission, some EDs may wish to perform medication reconciliation using this more comprehensive definition. 13
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org Safe Transitions Best Practice Measures
CLASSIFICATION: National Quality Strategy Priorities: Actual or Planned Use: Care Setting: Patient Condition: Data Source: Level of Analysis: Measure Type: Target Population: Making care safer by reducing harm caused in the delivery of care Promoting effective communication and coordination of care Quality improvement with benchmarking; contracting; pay for performance Emergency department Not applicable – all patients Medical record or electronic audit trail Practitioner, department or community (e.g., health system or state) Process measure All patients in the emergency department who are discharged home or to a skilled nursing or long‐term care facility MEASURE HISTORY: These measures were developed by Healthcentric Advisors, the Medicare Quality Improvement Organization for Rhode Island, using a multi‐stage stakeholder consensus process. The measures have since been updated. This process involved: 1) reviewing the medical literature (where it exists) and national campaigns and standards, 2) collecting input about community preferences, 3) drafting measures, and 4) and obtaining input (measure content and feasibility) and endorsement from the targeted provider group (EDs) and their partners (e.g., primary care providers and urgent care centers) and stakeholders (e.g., state agencies and payors). This quality improvement process was deemed exempt by the Rhode Island Department of Health’s Institutional Review Board. As a quality improvement project that incorporated local preference, these measures may not be generalizable to other states and regions, but can inform the development of local standards. MEASURE INFORMATION: CONSULTING SERVICES: Lynne Chase Senior Program Administrator, Healthcentric Advisors [email protected] or 401.528.3253 Kara Butler, MBA, MHA Senior Manager, Corporate Services, Healthcentric Advisors
[email protected] or 401.528.3221 MEASURE DEVELOPED: 2009 MEASURE LAST UPDATED: 23 September 2013 Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Hospital‐based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172(14):1057. Mills PR, McGuffie AC. Formal medicine reconciliation within the emergency department reduces the medication error rates for emergency admissions. Emerg Med J. 2010 Dec;27(12):911‐
5. 3
Joint Commission. National patient safety goal on reconciling medication information (Jt. Comm). Available at: http://www.jointcommission.org/standards_information/npsgs.aspx. Accessed Jan 17, 2013. 1 2
14
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org Safe Transitions Best Practice Measures
MEASURE: Effective education provided to patients prior to discharge MEASURE SET: Safe transitions best practice measures for emergency departments (Best Practice #7) MEASURE DESCRIPTION: This measure estimates the frequency with patients in the emergency department (ED) are provided with discharge education and evaluated to ensure their comprehension of that information. Timely and adequate information transfer is an important component of safe patient transitions between care settings and has been linked to improved patient experience and outcomes,1 but current practice often limits discharge education to the provision of written or verbal instructions, absent assessment of patient comprehension or the opportunity for patients to ask questions. There is a robust literature, particularly in the ED, which indicates patient comprehension of such information is low and may impact post‐discharge follow‐up care and medication adherence.2
NUMERATOR: Documentation that all of the following occurred prior to discharge:  Provision of patient education to the patient and informal caregiver (such as family),  Evidence that understanding of the education provided was assessed, and  An opportunity for the patient to ask questions. DENOMINATOR: All patients discharged home from the ED EXCLUSIONS: Patients discharged to a skilled nursing or facility or transferred from the ED to another acute‐care hospital RISK ADJUSTMENT: None – see exclusions DEFINITIONS Effective education: Education that incorporates testing of the patient’s understanding (e.g., use of a teach‐back method). Informal caregiver: A family member or other person who provides care and support to the patient. Patient education: Includes, at minimum: the ED diagnosis; any changes to medications and the reason for the change; condition‐specific “red flags” that should prompt the patient to seek medical attention and whom the patient should call; activity and other limitations; and recommended follow‐up appointments and tests.
NOTES: Communication with patients should incorporate concepts of health literacy and cultural competence and should adhere to interpreter requirements, per state and Federal law. 15
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org Safe Transitions Best Practice Measures
CLASSIFICATION: National Quality Strategy Priorities: Actual or Planned Use: Care Setting: Patient Condition: Data Source: Level of Analysis: Measure Type: Target Population: Ensuring that each person and family are engaged as partners in their care
Promoting effective communication and coordination of care Quality improvement with benchmarking; contracting; pay for performance Emergency department Not applicable – all patients Medical record or electronic audit trail Practitioner, department or community (e.g., health system or state) Process measure All patients discharged home from the ED MEASURE HISTORY: These measures were developed by Healthcentric Advisors, the Medicare Quality Improvement Organization for Rhode Island, using a multi‐stage stakeholder consensus process. The measures have since been updated. This process involved: 1) reviewing the medical literature (where it exists) and national campaigns and standards, 2) collecting input about community preferences, 3) drafting measures, and 4) and obtaining input (measure content and feasibility) and endorsement from the targeted provider group (EDs) and their partners (e.g., primary care providers and urgent care centers) and stakeholders (e.g., state agencies and payors). This quality improvement process was deemed exempt by the Rhode Island Department of Health’s Institutional Review Board. As a quality improvement project that incorporated local preference, these measures may not be generalizable to other states and regions, but can inform the development of local standards. MEASURE INFORMATION: CONSULTING SERVICES: Lynne Chase Senior Program Administrator, Healthcentric Advisors [email protected] or 401.528.3253 Kara Butler, MBA, MHA Senior Manager, Corporate Services, Healthcentric Advisors
[email protected] or 401.528.3221 MEASURE DEVELOPED: 2009 MEASURE LAST UPDATED: 23 September 2013 1
Snow V, Beck D, Budnitz T, Miller DC, Potter J, Wears RL, et al. Transitions of Care Consensus Policy Statement American College of Physicians‐Society of General Internal Medicine‐Society of Hospital Medicine‐American Geriatrics Society‐American College of Emergency Physicians‐Society of Academic Emergency Medicine. J Gen Intern Med. 2009; 24(8):971‐6. 2
Samuels‐Kalow ME, Stack AM, Porter SC. Effective discharge communication in the emergency department. Ann Emerg Med. 2012; 60(2):152‐9. 16
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org Safe Transitions Best Practice Measures
MEASURE: Written discharge instructions provided to patients prior to discharge MEASURE SET: Safe transitions best practice measures for emergency departments (Best Practice #8) MEASURE DESCRIPTION: This measure estimates the frequency with which patients in the emergency department (ED) are provided with written discharge instructions. Timely and adequate information transfer is an important component of safe patient transitions between care settings and has been linked to improved patient experience and outcomes.1 Patients discharged home from the ED are expected to self‐manage their follow‐up, and provision of written discharge instructions ensures that patients have information to refer to. It may also be helpful to downstream providers, if patients are coached to bring this information to follow‐up appointments. The multi‐disciplinary Transitions of Care Consensus Policy Statement also recommends that patients and informal caregivers (such as family members) “must receive, understand and be encouraged to participate in the development of a transition record [that takes] into consideration the patient’s health literacy and insurance status.”1 NUMERATOR: Documentation that written discharge instructions were provided to the patient and informal caregiver (such as family member) prior to discharge DENOMINATOR: All patients discharged home from the ED EXCLUSIONS: Patients discharged to a skilled nursing or facility or transferred from the ED to another acute‐care hospital RISK ADJUSTMENT: None – see exclusions DEFINITIONS Discharge Instructions: Should include, at a minimum, the information provided verbally as part of effective education (the ED diagnosis, any changes to medications and the reason for the change, condition‐specific “red flags” that should prompt the patient to seek medical attention and whom the patient should call, and recommended follow‐up appointments and tests), as well as the name of the ED clinician and ED contact information. Informal caregiver: A family member or other person who provides care and support to the patient. ED contact information: Phone number the patient can call for more information about the ED stay or discharge instructions, if needed.
NOTES: None 17
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org Safe Transitions Best Practice Measures
CLASSIFICATION: National Quality Strategy Priorities: Actual or Planned Use: Care Setting: Patient Condition: Data Source: Level of Analysis: Measure Type: Target Population: Ensuring that each person and family are engaged as partners in their care
Promoting effective communication and coordination of care Quality improvement with benchmarking; contracting; pay for performance Emergency department Not applicable – all patients Medical record or electronic audit trail Practitioner, department or community (e.g., health system or state) Process measure All patients discharged home from the ED MEASURE HISTORY: These measures were developed by Healthcentric Advisors, the Medicare Quality Improvement Organization for Rhode Island, using a multi‐stage stakeholder consensus process. The measures have since been updated. This process involved: 1) reviewing the medical literature (where it exists) and national campaigns and standards, 2) collecting input about community preferences, 3) drafting measures, and 4) and obtaining input (measure content and feasibility) and endorsement from the targeted provider group (EDs) and their partners (e.g., primary care providers and urgent care centers) and stakeholders (e.g., state agencies and payors). This quality improvement process was deemed exempt by the Rhode Island Department of Health’s Institutional Review Board. As a quality improvement project that incorporated local preference, these measures may not be generalizable to other states and regions, but can inform the development of local standards. MEASURE INFORMATION: CONSULTING SERVICES: Lynne Chase Senior Program Administrator, Healthcentric Advisors [email protected] or 401.528.3253 Kara Butler, MBA, MHA Senior Manager, Corporate Services, Healthcentric Advisors
[email protected] or 401.528.3221 MEASURE DEVELOPED: 2009 MEASURE LAST UPDATED: 23 September 2013 1
Snow V, Beck D, Budnitz T, Miller DC, Potter J, Wears RL, et al. Transitions of Care Consensus Policy Statement American College of Physicians‐Society of General Internal Medicine‐Society of Hospital Medicine‐American Geriatrics Society‐American College of Emergency Physicians‐Society of Academic Emergency Medicine. J Gen Intern Med. 2009; 24(8):971‐6. 18
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org Safe Transitions Best Practice Measures SELECTED SOURCES: Safe transitions best practice measures for emergency departments (EDs) These measures were developed by Healthcentric Advisors, the Medicare Quality Improvement Organization for Rhode Island, using a multi‐stage stakeholder consensus process. This process involved: 1) reviewing the medical literature (where it exists) and national campaigns and standards, 2) collecting input about community preferences, 3) drafting measures, and 4) obtaining input (measure content and feasibility) and endorsement from the targeted provider group (hospitals) and their community partners (e.g., primary care providers) and stakeholders (e.g., state agencies and payors). Selected sources from Steps #1 (the medical literature, national campaigns and standards) and #2 (community preferences) are below. Author, Year Discharge Setting Intervention or Observation Findings Related Best Practice Measure(s) for EDs American College of Emergency Physicians1 ED Set forth guidelines for the interhospital transfer of ED patients Guidelines include a recommendation that “appropriate medical summary and other pertinent records should accompany the patient to the receiving facility or be electronically transferred as soon as is practical.” Baren et al., 20062 ED Multifaceted intervention to improve PCP follow‐up after an ED asthma visit Compared to usual care, the two groups that received free prednisone, cab vouchers for a PCP appointment, and either a telephone reminder to schedule a visit or an appointment scheduled for them had higher PCP follow‐up rates. 7,8 Barlas et al., 19993 ED Instructions to obtain follow up within 48 hours after ED discharge A third of patients at risk for clinical deterioration, who are instructed to obtain follow‐up within 48 hours, do not do so. Rates were even lower if the patient was referred to a clinic or private physician vs. the ED. 8 Carrier et al., 20114 ED and PCPs Ability and willingness of EDs and PCPs to communicate and coordinate care Clinicians noted haphazard communication and poor coordination, which they felt undermined effective care. Correcting this may require information technology solutions, investments in care coordination and malpractice reform. 1,3,5 19
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org 5 Safe Transitions Best Practice Measures Author, Year Discharge Setting Intervention or Observation Findings Related Best Practice Measure(s) for EDs Chan et al., 20095 ED Internet‐based appointment scheduling system for patients without a PCP ED physicians were able to directly schedule appointments for high‐risk patients without PCPs. The frequency of follow up was much higher for intervention patients, although most still did not follow up as directed. Clarke et al., 20056 ED Assessment of comprehension of ED discharge instructions ED patients have poor reading skills. Comprehension was the only factor they tested that was positively correlated with compliance with discharge instructions. Hospital Provided a transitions coach to help improve patient education and self‐
management in the 30 days after hospital discharge Using the Care Transitions Intervention (CTI) chronically ill hospitalized patients and their caregivers to take a more active role in their care reduced rates of hospital readmission. The coaching tenets include assessing patient comprehension and helping patients use a personal health record, understand their condition, perform medication reconciliation and undertake recommended follow‐up. 6‐8 n/a Incorporated community preference (and later, input and endorsement) into the development of the Safe Transitions Best Practice Measures for EDs The multi‐stage stakeholder consensus process allowed Healthcentric Advisors: 1) to ensure that all of the best practice measures addressed the local causes of poor transitions and were feasible within the local context, and 2) to include best practices that were based on local needs, but not reflected in the medical literature and national campaigns or standards. 1,2 Coleman et al., 20097 Community Preference (Rhode Island) For example, community‐based primary care providers wanted EDs to ask each patient for his/her primary care provider’s name; this is a process step that enables EDs to send primary care provider summary clinical information in Best Practice 3, but is not reflected in the medical literature or in national campaigns or standards as a separate best practice. 20
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org 7,8 7 Safe Transitions Best Practice Measures Author, Year Discharge Setting Intervention or Observation Findings Related Best Practice Measure(s) for EDs Considine and Brennan, 20078 ED Educational intervention for ED nurses to improve discharge instructions Implementation of the educational intervention improved both the amount and the quality of discharge instructions given to parents of febrile children. 7,8 Engel et al., 20099 ED Assessment of patients' awareness of deficits in discharge instructions comprehension Many patients do not understand their discharge instructions; most of these patients are unaware that they do not understand and overconfident in their self‐assessment. 7 Friedman et al., 201010 ED Reasons for failure to complete recommended referral to specialty clinics A majority of patients discharged from the ED did not follow up with recommended specialist consultation. Most patients did not understand why the referral was made. 7 Beliefs about communication between nursing homes and EDs ED and nursing home clinicians who were surveyed felt important information was lost when patients were transferred between settings but varied by setting on what information should be available. All supported a role for verbal communication. 5 Gillespie et al., 201011 ED and nursing home Guttman et al., 200412 ED ED‐based nurse discharge plan coordinator Use of a discharge coordinator to educate patients, assist with appointments, and be available for questions reduced unscheduled return visits and improved satisfaction. 7 Hastings et al., 201113 ED Assessment of comprehension of ED discharge instructions and link to poor outcomes Many older patients and/or their caregivers do not understand ED discharge instructions; there was an association between not understanding one's diagnosis or its expected course and adverse events, but it did not reach statistical significance. 7 Hummel et al., 201014 ED Workflow mapping of medication reconciliation Many misperceptions exist among ED physicians and staff about what is required and how much patients know about their medications; identified improved processes. 6,7 21
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org Safe Transitions Best Practice Measures Author, Year Isaacman et al., 199215 Discharge Setting ED Intervention or Observation Standardization of discharge instructions Findings In a pediatric population with otitis media, the groups that received standardized discharge instructions had greater illness knowledge than controls; adding written instructions did not improve recall. Jack et al., 200916 Hospital Multifaceted package of discharge services Use of a nurse discharge advocate during hospitalization and a pharmacist post‐discharge decreased ED visits and readmissions. Joint Commission, 201317 Multiple Developed “National Patient Safety Goals” Along with other patient safety goals, the Joint Commission outlines expectations for medication reconciliation in the emergency department and hospital. Related Best Practice Measure(s) for EDs 8 1,3,6‐8 6 Kyriacou et al., 200518 ED Discharge process that included Follow‐up rates were low in the usual care group and improved scheduling an appointment for the patient with the intervention. Mills and McGuffie, 201019 ED Systematic medication reconciliation by a pharmacist Medication error rates were high before the intervention and decreased significantly afterward; medication reconciliation was more timely after the intervention. 6 Multiple Includes 34 Safe Practices for Better Healthcare that have been demonstrated to be effective in reducing the occurrence of adverse healthcare events, including poor care transitions The Safe Practices include recommendations for medication reconciliation and for discharge systems. Discharge systems must have: a “discharge plan” prepared for each patient at the time of hospital discharge, including a scheduled follow‐up appointment; standardized communication that occurs between the inpatient and outpatient clinicians; and the confirmed receipt of summary clinical information by receiving providers. 3‐8 National Quality Forum, 201020 22
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org 7,8 Safe Transitions Best Practice Measures Author, Year Discharge Setting Intervention or Observation Findings National Transitions of Care Coalition, 201121 Multiple Bundle of seven essential interventions applicable for any setting Naylor et al., 200422 Hospital Discharge planning and home follow‐up by A multifaceted intervention reduced time to readmission or advance practice nurses for elderly heart death and decreased readmissions overall. failure patients Patel et al., 200923 This bundle of essential care‐transition intervention strategies, applicable for any provider and any care transition, includes descriptions and examples of medication management, transition planning, patient and family engagement/education, information transfer, follow up care, healthcare provider engagement, and shared accountability across providers and organizations. Related Best Practice Measure(s) for EDs 1‐8 1,3,6‐8 ED Use of a bilingual discharge facilitator to reinforce discharge instructions in preferred language Among children with gastroenteritis, reinforcement of discharge instructions in parents' preferred language resulted in better recall of instructions, particularly among Spanish speakers. 7 Physician Consortium for Performance Improvement, 200924 ED, hospital Developed the “Care Transitions Performance Measurement Set (Phase I: Inpatient Discharges & Emergency Department Discharges)” Multiple physician professional societies came together to identify and define quality measures for patients undergoing care transitions. For patients discharged from the ED and hospital, suggested process measures included: 1) a transition record with specific minimum elements, 2) timely transmission of the transitions record, and 3) provision of medication reconciliation list to patients. 3‐8 Racine, et al., 200925 ED Follow‐up calls from PCP offices after pediatric ED use Calls from a patient's PCP office shortly after a pediatric ED visit to counsel about after‐hours access reduced subsequent ED use. 3 Rhodes et al., 200426 ED Analysis of audiotaped interactions between ED patients and clinicians, including discharge instructions Discharge instructions averaged 76 seconds and important elements, such as information on diagnosis, expected course and symptoms that should prompt return to the ED, were often absent. Patients were rarely asked if they had questions; no provider confirmed patient understanding of the information. 7 23
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org Safe Transitions Best Practice Measures Author, Year Robinson et al., 201227 Discharge Setting Intervention or Observation Findings Nursing Focus group and individual interviews with Identified barriers to safe transitions in nursing home residents, home and clinicians and patients such as residents' impaired cognition, as well as elements of ED successful transitions, such as effective communication. Related Best Practice Measure(s) for EDs 5 Samuels‐Kalow et al., 201228 ED Review of communication practices at time of ED discharge Patient comprehension at discharge is generally poor in multiple domains; interventions to improve comprehension, such as structured written and verbal instructions, can be moderately successful. 7,8 Schoen et al., 201229 ED Survey of PCPs Few PCPs were notified when their patients were seen in the ED; few PCPs have sufficient after‐hours care and same day visits to accommodate their patients. 1,3 Co‐authored by many physician professional societies, including the Society of Hospital Medicine; establishes principles and standards for managing transitions, including timely communication among providers and patient involvement. Suggests establishing local and national standards for continuous quality improvement and accountability. 3‐8 Snow et al., 200930 Multiple Developed consensus policy statement about care transitions Terrell and Miller, 200631 ED and nursing home Focus group interviews with nursing home Themes included current barriers, such as communication and ED clinicians problems, data needed in each setting, and potential solutions to improve transitions between EDs and nursing homes. 5 Terrell and Miller, 200732 ED and nursing home Review of care transitions interventions pertaining to the nursing home‐ED interface 5 Many communication problems during care transitions between the nursing home and ED were identified, including gaps in both written and verbal communication. Most interventions focused on improving the methods of existing communication. 24
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org Safe Transitions Best Practice Measures Author, Year Discharge Setting Intervention or Observation Findings Related Best Practice Measure(s) for EDs Terrell et al., 200933 ED Development of ED‐specific quality indicators for geriatric care Thomas et al., 199634 ED Determination of correlates of compliance Many patients missed recommended follow‐up appointments, with ED follow up instructions especially if they left the ED without an appointment scheduled. Lack of insurance and dissatisfaction with discharge instructions were independent correlates of not filling prescriptions. Vashi and Rhodes, 201135 ED Content analysis of ED discharge instructions In audiotaped discharge discussions, verbal instructions were often incomplete and patients' understanding was seldom assessed. 7 Vinson and Patel, 200936 ED Scheduling follow up appointments for patients prior to ED discharge In this integrated healthcare system, scheduling appointments resulted in good compliance with ED follow‐up recommendations. 7,8 Zavala and Shaffer, 201137 ED Follow‐up telephone call after ED discharge to assess if patients had questions about their discharge instructions About a third of patients requested more information about their discharge instructions; the same number described a diagnosis‐related concern that revealed poor comprehension of their instructions. 7,8 Zorc et al., 200938 ED Multifaceted intervention to address asthma beliefs and barriers Although the intervention influenced beliefs about the importance of PCP follow‐up, actual PCP visits remained low after a pediatric ED visit for asthma. Transitional care indicators included concepts related to critical data for the nursing home‐to‐ED transfer and for the ED‐to‐
nursing home transfer, tests requested by the nursing home, communication between settings, and care provided after the ED visit. MEASURE INFORMATION: CONSULTING SERVICES: Lynne Chase Senior Program Administrator, Healthcentric Advisors [email protected] or 401.528.3253 Kara Butler, MBA, MHA Senior Manager, Corporate Services, Healthcentric Advisors [email protected] or 401.528.3221 25
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org 5 7,8 7 Safe Transitions Best Practice Measures LAST UPDATED: 02 Oct 2013 KEY: 1.
2.
3.
4.
5.
6.
7.
8.
Documentation of patients’ primary care provider Documentation of patients’ home care provider Summary clinical information provided to primary care provider upon ED discharge Summary clinical information provided to home care provider upon ED discharge Summary clinical information provided to receiving provider upon ED discharge or transfer to another facility Medication reconciliation completed prior to discharge Effective education provided to patients prior to discharge Written discharge instructions provided to patients prior to discharge REFERENCES: American College of Emergency Physicians (ACEP). Appropriate interhospital patient transfer. Available at: http://www.acep.org/Content.aspx?id=29114. Accessed 02 Oct 2013. 1
2
Baren JM, Boudreaux ED, Brenner BE, Bydulka RK, Rowe BH, Clark S, et al. Randomized, controlled trial of emergency department interventions to improve primary care follow‐up for patients with acute asthma. Chest. 2006; 129(2):257‐65. 3
Barlas D, Homan CS, Rakowski J, Houck M, THode HC Jr. How well do patients obtain short‐term follow‐up after discharge from the emergency department? Ann Emerg Med. 1999; 34:610‐614. 4
Carrier E, Yee T, Holzwart RA. Coordination between emergency and primary care physicians. National Institute for Health Care Reform. 2011; Research Brief No. 3. Available at: http://www.nihcr.org/ED‐Coordination.html. Accessed Jan 17, 2013. 5
Chan TC, Killeen JP, Castillo EM, et al. Impact of an internet‐based emergency department appointment system to access primary care at safety net community clinics. Ann Emerg Med. 2009 Aug;54(2):279‐84. 6
Clarke C, Friedman SM, Shi K, Arenovich T, Monzon J, Culligan C. Emergency department discharge instructions comprehension and compliance study. CJEM. 2005; 7(1):5‐11. 7
Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. Sep 12 2005;165(16):1842‐
1847. 8
Considine J, Brennan D. Effect of an evidence‐based education programme on ED discharge advice for febrile children. J Clin Nurs. 2007 Sep;16(9):1687‐94. 26
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org Safe Transitions Best Practice Measures 9
Engel KG, Heisler M, Smith DM, Robinson CH, Forman JH, Ubel PA. Patient comprehension of emergency department care and instructions: are patients aware of when they do not understand? Ann Emerg Med. 2009 Apr;53(4):454‐461. 10
Friedman SM, Vergel de Dios J, Hanneman K. Noncompletion of referrals to outpatient specialty clinics among patients discharged from the emergency department: a prospective cohort study. CJEM. 2010 Jul;12(4):325‐30. 11
Gillespie SM, Gleason LJ, Karuza J, Shah M. Healthcare providers’ opinions on communication between nursing homes and emergency departments. J Am Med Dir Assoc. 2010; 11(3):204‐10. 12
Guttman A, Afilalo M, Guttman R, Colacone A, Robitaille C, Lang E, Rosenthal S. An emergency department‐based nurse discharge coordinator for elder patients: does it make a difference? Acad Emerg Med. 2004 Dec;11(12):1318‐27. 13
Hastings SN, Barrett A, Weinberger M, Oddone EZ, Ragsdale L, Hocker M, et al. Older patients' understanding of emergency department discharge information and its relationship with adverse outcomes. J Patient Saf. 2011; 7(1):19‐25. 14
Hummel J, Evans PC, Lee H. Medication reconciliation in the emergency department: opportunities for workflow redesign. Qual Saf Health Care. 2010 Dec;19(6):531‐5. 15
Isaacman DJ, Purvis K, Gyuro J, Anderson Y, Smith D. Standardized instructions: do they improve communication of discharge information from the emergency department? Pediatrics. 1992 Jun;89(6 Pt 2):1204‐8. 16
Jack BW, Cherry VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009; 150(3):178‐87. 17
Joint Commission. National patient safety goal on reconciling medication information (Jt. Comm). Available at: http://www.jointcommission.org/standards_information/npsgs.aspx. Accessed Jan 17, 2013. 18
Kyriacou DN, Handel D, Stein AC, Nelson RR. Brief Report: Factors affecting outpatient follow‐up compliance of emergency department patients. J Gen Intern Med. 2005; 20(10):938‐42. 19
Mills PR, McGuffie AC. Formal medicine reconciliation within the emergency department reduces the medication error rates for emergency admissions. Emerg Med J. 2010 Dec;27(12):911‐5. 20
National Quality Forum. Safe Practices. 2010. Available: http://www.qualityforum.org/Projects/Safe_Practices_2010.aspx, 11 Apr 2013. 21
National Transitions of Care Coalition. Care Transition Bundle Seven Essential Intervention Categories. 7 Feb 2011. Available: http://www.ntocc.org/Toolbox/ Accessed Oct 29, 2013. 22
Naylor MD, Brooten DA, Campbell RI, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004; 52(5):675‐84. 23
Patel B, Kennebeck SS, Caviness AC, Macias CG. Use of a discharge facilitator improves recall of emergency department discharge instructions for acute gastroenteritis. Pediatr Emerg Care. 2009 Sep;25(9):558‐64. 27
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org Safe Transitions Best Practice Measures 24
ABIM Foundation, American College of Physicians, Society of Hospital Medicine, The Physician Consortium for Performance Improvement (PCPI). Care transitions performance measurement set (Phase I: Inpatient discharges & emergency department discharges). Available at: http://www.abimfoundation.org/News/ABIM‐
Foundation‐News/2009/~/media/Files/PCPI%20Care%20Transition%20measures‐public‐comment‐021209.ashx. Accessed Jan 17, 2013. 25
Racine AD, Alderman EM, Avner JR. Effect of telephone calls from primary care practices on follow‐up visits after pediatric emergency department visits: evidence from the Pediatric Emergency Department Links to Primary Care (PEDLPC) randomized controlled trial. Arch Pediatr Adolesc Med. 2009 Jun;163(6):505‐11. 26
Rhodes KV, Vieth T, He T, Miller A, Howes DS, Bailey O, et al. Resuscitating the physician‐patient relationship: emergency department communication in an academic medical center. Ann Emerg Med. 2004; 44(3):262‐7. 27
Robinson CA, Bottorff JL, Lilly MB, Reid C, Abel S, Lo M, Cummings GG. Stakeholder perspectives on transitions of nursing home residents to hospital emergency departments and back in two Canadian provinces. J Aging Stud. 2012 Dec;26(4):419‐27. 28
Samuels‐Kalow ME, Stack AM, Porter SC. Effective discharge communication in the emergency department. Ann Emerg Med. 2012; 60(2):152‐9. 29
Schoen C, Osborn R, Squires D, Doty M, Rasmussen P, Pierson R, et al. A survey of primary care doctors in ten countries shows progress in use of health information technology, less in other areas. Health Aff. 2012; 31(12):2805‐16. 30
Snow V, Beck D, Budnitz T, Miller DC, Potter J, Wears RL, et al. Transitions of Care Consensus Policy Statement American College of Physicians‐Society of General Internal Medicine‐Society of Hospital Medicine‐American Geriatrics Society‐American College of Emergency Physicians‐Society of Academic Emergency Medicine. J Gen Intern Med. 2009; 24(8):971‐6. 31
Terrell KM and Miller DK. Challenges in transitional care between nursing homes and emergency departments. J Am Med Dir Assoc. 2006; 7:499‐505. 32
Terrell KM and Miller DK. Critical review of transitional care between nursing homes and emergency departments. Ann Long Term Care 2007; 15:33–8. 33
Terrell KM, Hustey FM, Hwang U, Gerson LW, Wenger NS, Miller DK; Society for Academic Emergency Medicine (SAEM) Geriatric Task Force. Quality indicators for geriatric emergency care. Acad Emerg Med. 2009 May;16(5):441‐9. 34
Thomas EJ, Burstin HR, O'Neil AC, Orav EJ, Brennan TA. Patient noncompliance with medical advice after the emergency department visit. Ann Emerg Med. 1996 Jan;27(1):49‐55. 35
Vashi A and Rhodes KV. “Sign right here and you’re good to go”: a content analysis of audiotaped emergency department discharge instructions. Ann Emerg Med. 2011; 57(4):315‐22. 36
Vinson DR, Patel PB. Facilitating follow‐up after emergency care using an appointment assignment system. J Healthc Qual. 2009 Nov‐Dec;31(6):18‐24. 37
Zavala S, Shaffer C. Do patients understand discharge instructions? J Emerg Nurs. 2011; 37(2):138‐40. 38
Zorc JJ, Scarfone RJ, Li Y, Hong T, Harmelin M, Grunstein L, et al. Scheduled follow‐up after a pediatric emergency department visit for asthma: a randomized trial. Pediatrics. 2003; 111(3):495‐502. 28
235 Promenade Street / Suite 500 / Box 18 / Providence, Rhode Island 02908 ~ Voice: 401.528.3200 / Fax: 401.528.3210 / healthcentricadvisors.org