Resources

 

Compass

ACMA’s Online Training Program for Case Management Nurses, Social Workers and Physician Advisors

ACTS

Simulation Training for Value-Based Results

Pfizer ArchiTools

Centralized resources for case managers containing articles and interactive training to achieve more positive outcomes for patients.

Transitions of Care References:

  1. Centers for Medicare and Medicaid Services (CMS). “Risk-Standardized Outcome and Payment Measures: Hospital Inpatient Quality Reporting (IQR) Program, Fiscal Year 2018.” Retrieved from https://www.ncqualitycenter.org/wp-content/uploads/2017/07/2017_CBM_FAQs.pdf
  2. Longitudinal care coordination: the key to improving care planning and patient outcomes.” Retrieved August 2018 from https://www.healthitoutcomes.com/longitudinal-carecoordination-the-key-to-improving-care-planning
  3. Ferket, K. (2016). The Care Continuum. In Mayzell, G. (Ed.) Population Health: An implementation guide to improve outcomes and lower costs. (p. 33-44). CRC Press.
  4. Fleming, Chris. “Health Policy Brief: Improving Care Transitions,” Health Affairs Blog, September 21, 2012.DOI: 10.1377/hblog20120921.023379
  5. gov. Hospital Compare: Measures and current data collection periods.  Retrieved from https://www.medicare.gov/hospitalcompare/Data/Data-Updated.html; August 2018.
  6. Pham, H, Grossman, JM, Cohen, G. Bodenheimer, T. (2008) “Hospitalists and care transitions: the divorce of inpatient and outpatient care.” Health Affairs, vol.27; no. 5. pp.1315-1327.
  7. Press, Matthew J. “Instant Replay – A Quarterback’s View of Care Coordination.” New England Journal of Medicine; vol. 371; no. 6, August 7, 2014, pp. 489-491.
  8. The Joint Commission. “Transitions of Care: The need for a more effective approach to continuing patient care.” June 2012 https://www.jointcommission.org/assets/1/18/Hot_Topics_Transitions_of_Care.pd

 

Related Works:

  1. Developed by Agency for Healthcare Research and Quality (AHRQ), the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) patient experience surveys are a quality improvement tool for health care organizations that use standardized data to identify relative strengths and weaknesses, determine where they need to improve, and track progress over time. There are unique CAHPS surveys for over a dozen care settings and patient populations.
  2. Centers of Medicare and Medicaid Services (CMS) Quality Metrics https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HospitalQualityInits/HospitalOutpatientQualityReportingProgram.html

    CMS has developed and implemented, under the direction of the US Congress, a variety of measures and care models with the purpose of providing financial incentives to providers to improve both the quality and the cost efficiency of care provided to Medicare and Medicaid patients. A variety of measures cover care settings and providers across the spectrum of healthcare delivery.

  1. CMS Medicare Shared Savings Program (MSSP) https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/sharedsavingsprogram/index.html?redirect=/sharedsavingsprogram/

    CMS establishes a voluntary alternate payment program that encourages groups of providers (doctors, hospitals and other providers) to create Accountable Care Organizations (ACOs). An ACO can improve beneficiary outcomes and increase value of care by providing: (1) Better care for individuals; (2) Better health for populations; and (3) Lowering growth in expenditures. The Shared Savings Program rewards ACOs that lower their growth in healthcare costs while meeting specific performance standards on quality of care and putting patients first.

  1. CMS – Medicare Part C and D Star Rating Program https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/PerformanceData.html

    Medicare Part C and D Star Rating Program is a national pay-for-performance program focused on MA plans for Part C (without prescription drug coverage) and Part D (with prescription drug coverage). Ratings of quality and performance are determined on overall performance using information from member satisfaction, providers and plans

  1. Dykes P, et al. A patient-centered longitudinal care plan: vision versus reality J Am Med Inform Assoc 2014; 21:1082–1090. doi:10.1136/amiajnl-2013-00245
  2. Elsevier: Longitudinal care coordination: the key to improving care planning and patient outcomes. Retrieved from https://www.healthitoutcomes.com/longitudinal-care-coordination-the-key-to-improving-care-planning
  3. Healthcare Effectiveness Data and Information Set (HEDIS) https://www.ncqa.org/hedis/

    HEDIS is a widely used set of performance measures in the managed care industry, developed and maintained by the National Committee for Quality Assurance (NCQA).  HEDIS was designed to allow consumers to compare health plans to national and regional benchmarks.  In 2018, HEDIS approved four care transition process metrics which the committee has endorsed as TOC Standard consensus process measures

  1. Hospital Compare: Measures and current data collection periods.  https://www.medicare.gov/hospitalcompare/data/data/updated
  2. Lamb, G. (2013) Care Coordination: the game changer. Nurse books/American Nurses Association, Silver Springs, MD. A compilation of authors discussing care coordination theory, practice and influence on quality and safety
  3. Levanthal, R (2018) Survey: 8 in 10 payers now putting social determinants of health into programs; Retrieved from: https://www.healthcare-informatics.com/page/reprints
  4. Merit-Based Incentive Payment System (MIPS) https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-BasedPrograms/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html

    Merit-Based Incentive Payment System (MIPS) is a payment program designed to reward value and outcomes in patient care. It is focused on individual eligible clinicians and group practices. The MIPS program combines the Physician Quality Reporting System, EHR Incentive Program, and Value-Based Payment Modifier into one unified program. Please note that the broader Quality Payment Program includes both MIPS and Alternative Payment Models (APMs). This is a new program, which will impact Medicare Fee-for-Service (FFS) provider payments in 2019 (with 2017 as the first performance period). Most of the care transition related measures listed are culled from the Improvement Activities performance category within MIPS, which assesses activities that improve clinical practice.

  1. New England Journal of Medicine, January 1, 2018; What is care coordination? Retrieved from https://catalyst.nejm.org/what-is-care-coordination/
  2. Nukels, TK, et al. Economic Evaluation of Quality Improvement Interventions Designed to Prevent Hospital Readmission A Systematic Review and Meta-analysis; Published Online: May 30, 2017. doi:10.1001/jamainternmed.2017.1136

    Systemic review and data analysis of economic evaluations based on 16700 patients.  Readmissions declined but net savings to hospitals were variable.

  1. NQF-Endorsed Measures for Care Coordination: Phase 3, 2014 Retrieved from: http://www.qualityforum.org/measures_reports_tools.aspx
  2. Press, Matthew J. (2014) Instant Reply-a quarterback’s view of care coordination. The New England Journal of Medicine; vol. 371; no.6, August 7, 2014
  3. Risk-Standardized Outcome and Payment Measures: Hospital Inpatient Quality Reporting (IQR) Program, Fiscal Year 2018. Retrieved from https://www.medicare.gov/frequentlyaskedquestions
  4. The Joint Commission, Hot Topics in Health Care.Transitions of Care:  The need for a more effective approach to continuing patient care. Retrieved from the transitions of care portal, tjc.org
  5. The Joint Commission, Hot Topics in Health Care. Transitions of Care: The need for collaboration across entire care continuum. Retrieved from the transitions of care portal, tjc.orgAHRQ Consumer Assessment of Healthcare Providers and Systems (CAHPS) https://www.ahrq.gov/cahps/index.html

Transitions of Care

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Funding and support for the Transitions of Care initiative is provided by Pfizer.