alice bonner, phd, rn executive director massachusetts senior care foundation
TRANSCRIPT
Alice Bonner, PhD, RNExecutive Director Massachusetts Senior Care Foundation
Poor care transitions disproportionately affect frail older adults and other vulnerable populations (Counsell et al, 2007)
Lack of coordination during transitions can lead to adverse events, poor clinical outcomes and rehospitalizations (Forster, 2003; Jencks, Williams & Coleman, 2009)
Efforts to improve care transitions in MA are underway, but lack planning and integration (Care Transitions Forum, Presentation to the MA Health Care Quality and Cost Council, May, 2009)
Multiple projects are underway State Action to Avoid Rehospitalizations (STAAR) Interventions to Reduce Acute Care Transfers
(INTERACT II) Medical Orders for Life Sustaining Treatment
(MOLST) Medical Home pilots with Community Health
Centers MA Division of Health Care Finance and Policy
Potentially Preventable Readmissions (PPR) project RWJ Aligning Forces grant (new – Boston only)
Multiple MA government entities are involved: Administration and Finance (Health Care
Payment Reform Commission) Health Care Quality and Cost Council (HCQCC) State Quality Improvement Institute (SQII) Elder Affairs (ADRCs, Long Term Care Financing
Task Force) Masshealth (pilots such as Senior Care Options
(SCO), transforming care of dual eligibles, case management of certain high risk populations, P4P for nursing homes)
MA Commission on HIT
1. Work with MA team to write Care Transitions strategic plan for the state (3-4 months; target completion date December 1st, 2009) Use strategic plan to guide integration of multiple
care transitions projects and align goals/objectives Examine whole systems measures (statewide)
2. Use process and outcome measures for a specific care transitions project (INTERACT II) in selected communities to focus the PCF proposal
INTERACT II (Interventions to Reduce Acute Care Transfers) www.interact.geriu.org
Goal: reduce avoidable transfers of nursing home residents back to the acute care setting
Intervention: a toolkit for nursing home staff▪ Clinical Care Paths and Resources▪ Communication tools (Stop & Watch; SBAR; Resident
Transfer Form; Envelope Checklist)▪ Advance Care Planning tools▪ QI Review Tool
Critical component: establish a cross-continuum team (relationship building)
Currently: 10 demonstration homes in MA, NY, FL
Implement INTERACT II tools and processes in at least 10 additional communities in Massachusetts
Reduce avoidable acute care transfer rates from nursing homes in those communities by 20%
Insure that at least 80% of the time, nursing home patients will arrive in the emergency department with 100% of the essential data required to manage the patient (or nursing homes using INTERACT II will improve by 10%)
State-level project All citizens in the Commonwealth (broadest
sense) Consider health disparities Consider unique aspects of rural health regions
Focus on nursing home population (primarily older adults) But keep other vulnerable populations in mind
for future dissemination (lifespan approach)
Outcome measures Medicare 30-day readmission rates by facility (all cause and
CHF)▪ We want to track readmissions at every point in time (many SNF patients
return within a short period of time). Working with DHCFP on data quality.▪ Berkowitz measure (unplanned discharge back to the hospital= number of
discharges back to the hospital/number of SNF admissions) Process measures under consideration
Resident/family experience with transfer (adaptation of CTM-3 or NH-CAHPS items)
Survey of implementation of INTERACT II by cross-continuum teams in communities (Are you using the tools? Which ones? How has it changed the way you are able to deliver care?)
Did essential data accompany the patient to the next setting of care, e.g., nursing home to ED?
Statewide Strategic Plan finished by December 1st
Rollout to other project teams by January 1st, 2010
INTERACT II demonstration sites complete data collection and analysis by April, 2010
Implementation of INTERACT II beyond the ten demonstration homes (additional Partners post-acute facilities) beginning in January, 2010
Data collection on Partners homes and hospitals begins April, 2010
Strategic plan needs to tie into health care payment reform initiatives, including cost containment
Plan (blueprint or roadmap) must guide us from isolated centers of excellence to effective statewide health policy and wider dissemination
My problem: I wasn’t in the right place to effect these changes
Director, Bureau of Health Care Safety and Quality, Department of Public Health Oversees licensing and certification of hospitals,
nursing homes, clinics, dialysis centers, home care agencies, ambulatory surgery centers
Includes the Division of Professional Licensure Includes Office of Emergency Management
Services (OEMS) Includes Drug Control Programs Includes Determination of Need Program Includes Betsy Lehman Center for Patient Safety
Massachusetts has some unique politics Massachusetts Hospital Association has a
history of voluntary reporting and working with government entities
Massachusetts Senior Care Association (nursing home trade group) has a history of wanting to play a significant role in improving care transitions
Massachusetts has several current funded care transitions projects to build on for dissemination
New Director of BORIM also interested in quality improvement
State-level opportunities for program sustainability: Regulatory channels (e.g., DPH sanctions) Legislative channels (MA Chapter 305 of
Health Care Reform legislation) Financial incentives (P4P, other) Payment Reform (Healthcare Payment
Reform Commission)
There is a lot of networking to be done
There is a lot of politics to understand
Has anyone been part of a similar initiative in other states or regions?
Do you think it makes sense to move ahead with this agenda, or wait until national health care reform legislation is passed?
Suggestions for how to focus on specific project goals and metrics with INTERACT II