Care Transitions Emphasized: Measures Could Ease ED Care Transitions

ACEP News
December 2009

By Diana Mahoney
Elsevier Global Medical News

BOSTON -- New performance measures designed to evaluate and improve outcomes for patients undergoing transitions in care should also go a long way toward improving emergency physicians' job satisfaction, Dr. Susan M. Nedza said.

"Right now, it's hard to go home feeling good at the end of the day when you're worried about patients whom you discharged [from the emergency department] off to who knows where," said Dr. Nedza of Northwestern University, Chicago, and vice president of clinical quality and patient safety for the American Medical Association.

"This is not just about the risks once you admit somebody. It's also about what happens when you send them out the door with instructions to see a doctor in 2 days," she said at a meeting titled "Improving the Quality and Efficiency of Emergency Care Across the Continuum: A Systems Approach." She added, "All of us have been a little afraid to do the study to find out how many of those patients actually get that follow-up care. My guess is that it's probably a number that we would not be proud of."

The new measures, defined by a Care Transitions Work Group (CTWG) comprising experts from the American Board of Internal Medicine Foundation, the American College of Physicians, the Society of Hospital Medicine, and the Physician Consortium for Performance Improvement (PCPI), represent an effort to improve care transition processes, said Dr. Nedza. Multiple studies have linked uncoordinated transitions between sites of care and caregivers, even within the same institution, to higher hospital readmission rates, medical errors, duplication of services, and waste of resources, she noted.

Importantly, the proposed measures are not individual performance measures, but instead are team-based, she explained. "This can't just be about measuring doctors' performances. In order to bring about quality improvement, it also has to be about the hospital, about EMS [emergency medical services], and about other related health care systems," said Dr. Nedza, an emergency physician and a former member of the American College of Emergency Physicians Board of Directors.

As such, the measures are meant to be used by physicians, other health professionals, and health care systems to analyze and improve the care of all patients discharged from an emergency department or inpatient facility to care in post-acute inpatient or ambulatory care settings, said Dr. Nedza. "This is very important in emergency medicine, because we are so dependent on the environments in which we practice."

To develop the measures, the CTWG identified indicators of success for improving the outcomes of patients undergoing transitions in care, as well as process measures linked to them, Dr. Nedza explained.

The success indicators include reductions in adverse drug events, reductions in patient harm related to medical errors of omission and commission, reductions in unnecessary health care encounters, reductions in redundant tests and procedures, achievement of patient goals and preferences, and improved patient understanding of and adherence to treatment plans, she said.

The associated process measures include the timely transfer of information across settings and among professionals involved in care transitions, effective coordination of transitions, timely delivery of care, and efforts to improve patient understanding of treatment plans, patient awareness of emergency provider contact information, and patient engagement in care, she said.

The work group recommended the following Care Transition measures, which were approved by PCPI in June 2009 and are being tested in various settings, said Dr. Nedza:

  • Reconciled medication list received by discharged patients.
  • Transition record with specified elements received by discharged patients.
  • Timely transmission of transition record (to facility or primary physician for follow-up care).
  • Transition record with specified elements received by discharged patients in the emergency department.
  • Discharge planning/post-discharge support for heart failure patients. Discharge planning/post-discharge support for heart failure patients.

The first three "are composite measures intended for inpatient discharges to home or other site of care and should be bundled," she said. "[Providers] can't pick and choose. They will have to hit on all three to get credit." The fourth measure is specifically intended for emergency department discharges.

In addition, according to the AMA executive summary of the Care Transitions performance measurement set, the CTWG is working toward the intermediate objective of promoting improved patient understanding of and adherence to the post-discharge treatment plan through the addition of appropriate questions to the Consumer Assessment of Healthcare Providers and Systems (CAHPS) hospital survey (www.ama-assn.org/ama1/pub/upload/mm/370/care-transitions-ms.pdf).

As with all quality measures, the Care Transition performance measures "can contribute to the improvement of patient care only when they are linked to initiatives that care providers, health care systems, insurers, and patients can use in practice to improve performance," said Dr. Nedza.

With respect to medication reconciliation, for example, the AMA has developed and is beta-testing a prototype electronic medication reconciliation card designed to avoid potential adverse events and inappropriate prescriptions, as well as an electronic care transition tool to facilitate the transfer of care coordination information between health care providers and settings, said Dr. Nedza.

In addition, "the AMA is involved in the development and testing of a decision support platform--the Flu Information Care System--to help health care providers and systems meet patient and community needs surrounding H1N1," Dr. Nedza noted.

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