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Perspectives: NQF Endorsed Practices and Quality Measures Support Coordinated Healthcare

As the number of healthcare professionals, care settings, and treatments involved in a patient’s care has increased, the coordination of care has become both more difficult and more vital.  Poorly coordinated care often results in wasted healthcare dollars and worse care for patients. The average patient is passed between doctors approximately 15 times during a single five-day hospitalization, and taxpayers spend at least $15 billion each year treating Medicare patients who, partly due to poor coordination, get worse after discharge and must be readmitted. 
 
Care coordination is especially important for people with chronic conditions, such as diabetes or congestive heart failure, who often receive care in multiple settings from numerous providers. These individuals may see up to 16 physicians a year.  In 2000, 125 million people in the United States were living with at least one or more chronic illness — a number that is expected to grow to 157 million by 2020, according to a 2009 article in the New England Journal of Medicine.   As this ever-growing group attempts to navigate our complex healthcare system and transition from one care setting to another, they often are unprepared or unable to manage their care.  Incomplete or inaccurate transfer of information, poor communication, and a lack of appropriate follow-up care can lead to confusion and poor outcomes, including medication errors and often preventable hospital readmissions and ED visits.
 
Healthcare cannot be of high quality if it is not delivered in a well-coordinated, efficient manner.  Effective care coordination means that patient and family needs and preferences for care are understood and that accountable structures and processes are in place for communication and the integration of a comprehensive plan of care across providers and settings. Care among many different providers must be well coordinated to avoid waste; over-, under-, or misuse of prescribed medications and treatment regimens; and conflicting plans of care.
 
In 2006, the National Quality Forum (NQF), an organization dedicated to improving healthcare quality endorsed a definition of and framework for care coordination. The framework identified five key domains: Healthcare Home; Proactive Plan of Care and Follow-up; Communication; Information Systems; and Transitions or Handoffs. In addition to endorsing a definition and framework, NQF, in its role as a convener and partner in the National Priorities Partnership (NPP), has focused on care coordination. Specifically, the Partnership identified the following goals:
  • Improve care and achieve quality by facilitating and carefully considering feedback from all patients regarding coordination of their care;
  • Improve communication around medication information;
  • Work to reduce 30-day readmission rates; and
  • Work to reduce preventable emergency department (ED) visits by 50 percent.

Following its endorsement of a definition and framework, NQF embarked on a full consensus project to endorse a set of preferred practices and performance measures for care coordination that are applicable across all settings of care and identify high-priority research areas to advance the evaluation of care coordination as a quality improvement tool. This project, completed early in 2010, led to the endorsement of a set of 25 preferred practices and 10 performance measures.

Among the performance measures that NQF endorsed in its 2010 report was the 3-Item Care Transitions Measure.  This consensus standard is of special significance as it is a measure of the patient’s perception of the quality of care coordination (specific to the hospital setting). This three-question survey is important because care can be provided in a technically coordinated fashion but is only truly coordinated if the patient perceives it as such.

3-Item Care Transitions Measure
  1. he hospital staff took my preferences and those of my family or caregiver into account in deciding what my healthcare 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.
Two other NQF endorsed measures specifically addressed emergency department care:
  • Patients with a transient ischemic event ER visit who had a follow-up office visit, and
  • Transition record with specified elements received by discharged patients (emergency department discharges to ambulatory care [home/self care]).
Currently, several pilot and demonstration projects that hold promise for care coordination are underway. Most of these are either just being implemented or are in various stages of completion. The following are two noteworthy initiatives;

Hospital 2 Home: Excellence in Transitions
The Hospital to Home (H2H) initiative, developed by the American College of Cardiology and the Institute for Healthcare Improvement (IHI), is seeking to reduce the 30-day, all-cause hospital readmission rates among patients discharged with heart failure or acute myocardial infarction by 20 percent nationally by December 2012. This “excellence in transitions” project, which is modeled after successful national initiatives by both organizations, is building a community of hospitals, healthcare systems, clinical practices, and collaborators dedicated to reducing preventable hospital readmissions; is providing straightforward, evidence-based recommendations for improving transitions; and will disseminate customizable ideas, tools, and strategies.
 
Care Transitions
Fourteen Medicare Quality Improvement Organizations (QIOs) across the nation are working on care transitions with support from the Care Transitions Quality Improvement Organization Support Center (QIOSC). QIOs will promote seamless transitions from the hospital to home, skilled nursing care, or home health care, and will work to reduce unnecessary readmissions to hospitals that may increase risk or harm to patients and cost to Medicare. CMS will look to QIOs to implement projects that effect process improvements to address issues in medication management, post-discharge follow-up, and plans of care for patients who move across healthcare settings.  The three-year project runs through July 2011. Projects include:
  • Educating patients before discharge on their medicine, diagnosis, and the need for follow care;
  • Giving patients pill planners; and
  • Making follow up calls.
Collectively, the evidence these and other projects are gathering will point the way toward the formation of a healthcare system that is truly coordinated, to the ultimate benefit of the patient.
 
As San Francisco physician and care coordination advocate Thomas Bodenheimer, MD, has noted, improvement in care coordination requires that different healthcare entities, sometimes working in competition, perform together. This requires the setting aside of parochial interests and placing the patient at the center of care. Only then can all care be coordinated for every patient every day.

NQF’s Final Report on Care Coordination

Helen Burstin, MD, MPH, Senior Vice President for Performance Measures, National Quality Forum