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Safe Transitions
Best Practice Measures
for
Nursing Homes
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 (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. 11SOWQIN-C2_042015_1193
Safe Transitions Best Practice Measures
MEASURE:
Safe transitions best practice measures for nursing homes
MEASURES:
The best practice measures for nursing homes are eleven (11) process measures:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Interventions implemented for residents at highest risk for unplanned transfer
Clinical information sent with emergency department referrals
Real-time verbal information provided to emergency department or hospital clinicians, if needed
Medication reconciliation completed after emergency department or hospital discharge
Structured communication used for clinical questions to physicians
End-of-life care discussed with residents
Effective education provided to residents prior to nursing home discharge
Written discharge instructions provided to residents prior to nursing home discharge
Follow-up appointment scheduled prior to nursing home discharge
Summary clinical information provided to outpatient physician(s) at discharge
Residents have access to medication after nursing home discharge
PURPOSE:
The best practice measures are intended to improve provider-to-provider communication and patient activation during
patient transitions between any two settings. Nursing homes 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 all patients in or recently transitioned from nursing homes
CARE SETTING:
Nursing homes, including skilled nursing and/or long-term care facilities
RECIPROCAL MEASURES:
In addition to the best practices for urgent care centers, Healthcentric Advisors developed five (5) additional sets of
setting-specific measures, for:
1.
2.
3.
4.
5.
Community physician offices
Emergency departments
Home health agencies
Hospitals
Urgent care centers
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
Safe Transitions Best Practice Measures
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.
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 (skilled nursing and/or long-term care) and their
community partners (e.g., primary care providers) 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
Massachusetts Program Director, Healthcentric Advisors
lchase@healthcentricadvisors.org or 877.904.0057 X3253
Kara Butler, MBA, MHA
Senior Manager, Corporate Services, Healthcentric Advisors
kbutler@healthcentricadvisors.org or 401.528.3221
LAST UPDATED:
18 February 2014
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
Safe Transitions Best Practice Measures
MEASURE:
Interventions implemented for residents at highest risk for unplanned transfer
MEASURE SET:
Safe transitions best practice measures for nursing homes (Best Practice #1)
MEASURE DESCRIPTION:
This measure estimates the frequency with which nursing homes implement interventions for residents at highest risk
for unplanned transfer. Given the frailty and medical co-morbidities of the nursing home population, all residents are at
higher risk than most other individuals for transfers to the emergency department (ED) and hospital. Identifying nursing
home residents at the highest risk for unplanned transfer allows for implementation of targeted interventions.
Individuals in nursing homes obtain care from a diverse group of providers and experience frequent transitions between
care settings. Research has demonstrated that that hospitalizations are everyday occurrences among both short- and
long-stay residents, and transfers may take place without extensive discussion among staff, for a variety of complex
reasons outlined below.1 Coordinated care, ready access to clinical information and timely communication is especially
important for this population and may reduce readmissions and improve quality of care.2
Risk factors for unplanned transfers may include: history of non-adherence with recommended treatment; severe
depression; acute change in mental, emotional or behavioral status; history of falls; and recent hospitalizations. The
Kaiser Family Foundation has identified the following additional factors: limited on-site nursing home capacity for
medical issues, physician preference for care in inpatient facility, liability concerns for facilities, physician or facility
financial incentives, lack of advance care planning, reluctance of family members to second guess physician’s decision to
hospitalize and behavioral health issues.1
NUMERATOR:
Documentation of implementation of interventions to address identified risks
DENOMINATOR:
Nursing home residents meeting highest risk criteria
EXCLUSIONS:
None
RISK ADJUSTMENT:
None
DEFINITIONS
High-risk:
Risk factors may include (but are not limited to):
 History of non-adherence with recommended treatment,
 Severe depression,
 Acute change in mental, emotional, or behavioral status,
 Patient and family preferences for hospitalization,
 Physician preferences for hospitalization,
 History of falls (≥2 in the past year or any fall with an injury in the past year), and
 ≥2 hospitalizations in the prior 12 months.
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
Safe Transitions Best Practice Measures
Interventions: Targeted strategies to reduce residents’ specific risks for unplanned transfer.
Unplanned
transfer:
Transport of a resident from a nursing home to an acute care facility, such as a hospital
emergency department, for management of an escalating medical or surgical problem.
NOTES:
High risk characteristics may be identified during initial or ongoing assessments.
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
Nursing homes, including skilled nursing and/or long-term care facilities
Not applicable – all patients
Medical record or electronic audit trail
Practitioner, unit, facility or community (e.g., health system or state)
Process measure
All nursing home residents, including those receiving skilled services
MEASURE HISTORY:
This measure was developed by Healthcentric Advisors, the Medicare Quality Improvement Organization for Rhode
Island, using a multi-stage stakeholder consensus process. It has 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 (skilled nursing and/or long-term care) and their
community partners (e.g., PCPs) 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, this measure (and the other Safe Transitions Best Practice Measures for
Nursing Homes) may not be generalizable to other states and regions, but can inform the development of local
standards.
MEASURE INFORMATION:
Lynne Chase
Massachusetts Program Director, Healthcentric Advisors
lchase@healthcentricadvisors.org or 877.904.0057 X3253
CONSULTING SERVICES:
Kara Butler, MBA, MHA
Senior Manager, Corporate Services, Healthcentric Advisors
kbutler@healthcentricadvisors.org or 401.528.3221
MEASURE DEVELOPED:
2009
MEASURE LAST UPDATED:
18 February 2014
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
Safe Transitions Best Practice Measures
MEASURE:
Clinical information sent with emergency department referrals
MEASURE SET:
Safe transitions best practice measures for nursing homes (Best Practice #2)
MEASURE DESCRIPTION:
This measure estimates the frequency with which nursing homes send clinical information to the emergency
department (ED), when referring a resident for evaluation.
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.3 The Transitions of Care Consensus Conference
recommends timely communication that includes both providers (sending and receiving) involved in a patient’s care.1
ED clinicians express a desire to have pertinent, up-to-date clinical information accompany patients arriving from
nursing homes.4 This information transfer allows ED clinicians to more effectively focus their work-up and management
strategies, without repeat testing or duplication of other services, and ensures that the nursing home provider’s specific
concerns are adequately addressed.
NUMERATOR:
Documentation of provision of clinical information and contact information by the nursing home to the ED either:
 At the time of resident referral, or
 Within one hour of resident referral, if the resident is sent emergently
DENOMINATOR:
All residents referred to the ED
EXCLUSIONS:
None
RISK ADJUSTMENT:
None
DEFINITIONS
Clinical information:
Written information that includes the resident’s baseline status, main reason for referral to the
ED, expectation, advance directives (if present), problem list, medication list, and applicable labs.
Contact information: A phone number connecting the ED to nursing home staff who can address the ED clinician’s
clinical question.
Emergently:
Clinical deterioration that occurs unexpectedly and requires immediate transfer to the ED.
NOTES:
The clinical information can be transmitted from the nursing home to the ED with the patient or via fax, email or other
electronic means.
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
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
Nursing homes, including skilled nursing and/or long-term care facilities
Not applicable – all patients
Medical record or electronic audit trail
Practitioner, unit, facility or community (e.g., health system or state)
Process measure
All nursing home residents referred to ED
MEASURE HISTORY:
This measure was developed by Healthcentric Advisors, the Medicare Quality Improvement Organization for Rhode
Island, using a multi-stage stakeholder consensus process. It has 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 (skilled nursing and/or long-term care) and their
community partners (e.g., primary care providers) 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, this measure (and the other Safe Transitions Best
Practice Measures for Nursing Homes) may not be generalizable to other states and regions, but can inform the
development of local standards.
MEASURE INFORMATION:
Lynne Chase
Massachusetts Program Director, Healthcentric Advisors
lchase@healthcentricadvisors.org or 877.904.0057 X3253
CONSULTING SERVICES:
Kara Butler, MBA, MHA
Senior Manager, Corporate Services, Healthcentric Advisors
kbutler@healthcentricadvisors.org or 401.528.3221
MEASURE DEVELOPED:
2009
MEASURE LAST UPDATED:
18 February 2014
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
Safe Transitions Best Practice Measures
MEASURE:
Real-time verbal information provided to emergency department or hospital clinicians, if needed
MEASURE SET:
Safe transitions best practice measures for nursing homes (Best Practice #3)
MEASURE DESCRIPTION:
This measure estimates the frequency with which nursing homes respond to emergency department (ED) and hospital
clinicians’ verbal requests for time-sensitive clinical information at the time of the initial call or within one hour.
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, and the Transitions of Care Consensus Conference
recommends timely communication that includes both providers (sending and receiving) involved in a patient’s care.5
Although clinicians in the ED and nursing home settings recognize the importance of communication during care
transitions, both groups acknowledge that communication is often inadequate between these settings.6
NUMERATOR:
Documentation that if an ED or hospital clinician called the nursing home, one of the following occurred:
 A conversation between the ED or hospital clinician and a nursing home staff member at the time of the initial call,
or
 A return phone call from a nursing home staff member within 1 hour of the ED or hospital clinician’s phone call to
the nursing home
DENOMINATOR:
All residents whose care requires phone calls from the ED or hospital to the nursing home for time-sensitive clinical
questions
EXCLUSIONS:
None
RISK ADJUSTMENT:
None
DEFINITIONS
ED or hospital clinician:
Nursing home staff member:
Physician, Nurse Practitioner, Physician Assistant, or nurse who is taking care of the
resident.
Clinical or clerical staff who can address the ED or hospital clinician’s specific question.
Time-sensitive clinical question: Whether or not a resident’s care “requires” a conversation and in what timeframe is a
subjective determination left to the ED or hospital clinician’s discretion, with the
understanding that outreach is intended to be limited to situations where information is
needed quickly to inform the patient’s care.
NOTES:
None
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
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
Nursing homes, including skilled nursing and/or long-term care facilities
Not applicable – all patients
Medical record or electronic audit trail
Practitioner, unit, facility or community (e.g., health system or state)
Process measure
All nursing home residents, including those receiving skilled services
MEASURE HISTORY:
This measure was developed by Healthcentric Advisors, the Medicare Quality Improvement Organization for Rhode
Island, using a multi-stage stakeholder consensus process. It has 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 (skilled nursing and/or long-term care) and their
community partners (e.g., PCPs) 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, this measure (and the other Safe Transitions Best Practice Measures for
Nursing Homes) may not be generalizable to other states and regions, but can inform the development of local
standards.
MEASURE INFORMATION:
Lynne Chase
Massachusetts Program Director, Healthcentric Advisors
lchase@healthcentricadvisors.org or 877.904.0057 X3253
CONSULTING SERVICES:
Kara Butler, MBA, MHA
Senior Manager, Corporate Services, Healthcentric Advisors
kbutler@healthcentricadvisors.org or 401.528.3221
MEASURE DEVELOPED:
2009
MEASURE LAST UPDATED:
18 February 2014
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
Safe Transitions Best Practice Measures
MEASURE:
Medication reconciliation completed after emergency department or hospital discharge
MEASURE SET:
Safe transitions best practice measures for nursing homes (Best Practice #4)
MEASURE DESCRIPTION:
This measure estimates the frequency with which nursing homes perform medication reconciliation after their residents
are discharged from the emergency department (ED) or hospital.
Medication errors are common, and studies have shown that medication reconciliation is associated with decreased risk
for adverse drug events.7,8,9 Medication reconciliation is a Joint Commission patient safety goal and can help to ensure
that nursing home providers identify potential medication errors and understand which medications to stop, start or
adjust after a resident visits an ED or hospital. Studies demonstrate that medication errors or discrepancies are relatively
common at hospital discharge (occurring among 14% of elderly patients) and are associated with a higher risk of poor
outcomes and hospital readmission.10
NUMERATOR:
Documentation of medication reconciliation within 24 hours of transfer from the hospital or ED to the nursing home
DENOMINATOR:
All residents discharged from the hospital or ED
EXCLUSIONS:
None
RISK ADJUSTMENT:
None
DEFINITIONS
Medication reconciliation:
The process of: 1) reviewing the patient’s discharge medication regimen (name, dose,
route, frequency, and purpose) and 2) comparing the discharge medication regimen to
their prior medication regimen to identify and resolve any discrepancies.
NOTES:
None
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
Nursing homes, including skilled nursing and/or long-term care facilities
Not applicable – all patients
Medical record or electronic audit trail
Practitioner, unit, facility or community (e.g., health system or state)
Process measure
All nursing home residents discharged from the hospital or ED
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
Safe Transitions Best Practice Measures
MEASURE HISTORY:
This measure was developed by Healthcentric Advisors, the Medicare Quality Improvement Organization for Rhode
Island, using a multi-stage stakeholder consensus process. It has 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 (skilled nursing and/or long-term care) and their
community partners (e.g., PCPs) 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, this measure (and the other Safe Transitions Best Practice Measures for
Nursing Homes) may not be generalizable to other states and regions, but can inform the development of local
standards.
MEASURE INFORMATION:
Lynne Chase
Massachusetts Program Director, Healthcentric Advisors
lchase@healthcentricadvisors.org or 877.904.0057 X3253
CONSULTING SERVICES:
Kara Butler, MBA, MHA
Senior Manager, Corporate Services, Healthcentric Advisors
kbutler@healthcentricadvisors.org or 401.528.3221
MEASURE DEVELOPED:
2009
MEASURE LAST UPDATED:
18 February 2014
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
Safe Transitions Best Practice Measures
MEASURE:
Structured communication used for clinical questions to physicians
MEASURE SET:
Safe transitions best practice measures for nursing homes (Best Practice #5)
MEASURE DESCRIPTION:
This measure estimates the frequency with which nursing home clinicians use structured communication for clinical
questions to physicians about nursing home residents. Given the frailty and medical co-morbidities of the nursing home
population, effective communication is especially important in providing quality care for these residents and a failure of
this communication may lead to adverse events.1
Tools for structured communication, such as SBAR11, provide a foundation for more effective and consistent transfer of
information within a nursing home and from the nursing home to a hospital or emergency department, when a resident
is transferred. Nurses and physicians are trained to communicate in different ways; use of structured communication
can help to bridge these different communication styles and ensure that patient information is shared in a concise
format. Structured communication improves patient safety because clinicians can communicate with each other with a
shared set of expectations.
NUMERATOR:
Documentation of use of structured communication, such as SBAR
DENOMINATOR:
All verbal communication with physicians
EXCLUSIONS:
None
RISK ADJUSTMENT:
None
DEFINITIONS
SBAR:
Situation-Background-Assessment-Recommendation; a communication framework for inter-provider
discussions to ensure that high-urgency concerns are addressed efficiently.
NOTES:
Facilities might find it helpful to develop a formal physician communication policy—a written policy that is part of newhire and occasional recurring staff training.
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
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
Nursing homes, including skilled nursing and/or long-term care facilities
Not applicable – all patients
Medical record or electronic audit trail
Practitioner, unit, facility or community (e.g., health system or state)
Process measure
All nursing home residents, including those receiving skilled services
MEASURE HISTORY:
This measure was developed by Healthcentric Advisors, the Medicare Quality Improvement Organization for Rhode
Island, using a multi-stage stakeholder consensus process. It has 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 (skilled nursing and/or long-term care) and their
community partners (e.g., PCPs) 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, this measure (and the other Safe Transitions Best Practice Measures for
Nursing Homes) may not be generalizable to other states and regions, but can inform the development of local
standards.
MEASURE INFORMATION:
Lynne Chase
Massachusetts Program Director, Healthcentric Advisors
lchase@healthcentricadvisors.org or 877.904.0057 X3253
CONSULTING SERVICES:
Kara Butler, MBA, MHA
Senior Manager, Corporate Services, Healthcentric Advisors
kbutler@healthcentricadvisors.org or 401.528.3221
MEASURE DEVELOPED:
2009
MEASURE LAST UPDATED:
18 February 2014
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
Safe Transitions Best Practice Measures
MEASURE:
End-of-life care discussed with residents
MEASURE SET:
Safe transitions best practice measures for nursing homes (Best Practice #6)
MEASURE DESCRIPTION:
This measure estimates the frequency with which nursing homes discuss end-of-life care with residents. This best
practice goes beyond routine discussions about code status that may occur during the admissions process.
While residents may have advance directive documents, often these items are not well understood or discussed among
residents, families and medical providers. It is not always clear who is responsible to speak on the resident’s behalf
around end-of-life care or who should take the lead in updating advance directives. This ambiguity can lead to confusion
during medical emergencies and ultimately may result in undesired hospitalizations.12
Transfers at the end-of-life can severely diminish quality of life. Any transfer should occur in the context of the resident’s
expressed wishes or those of the resident’s surrogate decision maker.13 Discussing end-of-life care may help avoid
unwanted transfers or unwanted treatments by exploring the resident’s goals and values so that any offered medical
care can be aligned with an individual resident’s wishes.
It may also be helpful to shift the focus of end-of-life discussions away from completion of advance directives; instead,
nursing homes may wish to use these discussions to prepare residents and their families to participate with clinicians to
make the best possible in-the-moment medical decisions.14 In other words, these discussions can prepare residents for
the types of decisions and conflicts that may occur in the future, without requiring them to specify exactly what
treatments they would want.
NUMERATOR:
Documentation of resident, family, or caregiver’s participation in end-of-life discussions
DENOMINATOR:
Residents whose care requires end-of-life discussions
EXCLUSIONS:
Residents who:



Refuse this discussion,
Are unable to participate, or
Do not have family or caregivers willing or able to participate.
RISK ADJUSTMENT:
None – see exclusions
DEFINITIONS
Caregiver:
A person who provides care and support to the resident.
End-of-life discussions: Conversations and decision-making regarding end-of-life topics such as comfort care only,
change of code status, do-not-hospitalize orders, hospice, and other related goals of care. This
process may also be called advance care planning.
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
Safe Transitions Best Practice Measures
NOTES:
None
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
Nursing homes, including skilled nursing and/or long-term care facilities
Not applicable – all patients
Medical record or electronic audit trail
Practitioner, unit, facility or community (e.g., health system or state)
Process measure
All nursing home residents, including those receiving skilled services
MEASURE HISTORY:
This measure was developed by Healthcentric Advisors, the Medicare Quality Improvement Organization for Rhode
Island, using a multi-stage stakeholder consensus process. It has 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 (skilled nursing and/or long-term care) and their
community partners (e.g., PCPs) 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, this measure (and the other Safe Transitions Best Practice Measures for
Nursing Homes) may not be generalizable to other states and regions, but can inform the development of local
standards.
MEASURE INFORMATION:
Lynne Chase
Massachusetts Program Director, Healthcentric Advisors
lchase@healthcentricadvisors.org or 877.904.0057 X3253
CONSULTING SERVICES:
Kara Butler, MBA, MHA
Senior Manager, Corporate Services, Healthcentric Advisors
kbutler@healthcentricadvisors.org or 401.528.3221
MEASURE DEVELOPED:
2009
MEASURE LAST UPDATED:
18 February 2014
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
Safe Transitions Best Practice Measures
MEASURE:
Effective education provided to residents prior to nursing home discharge
MEASURE SET:
Safe transitions best practice measures for nursing homes (Best Practice #7)
MEASURE DESCRIPTION:
This measure estimates the frequency with which nursing home residents 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,15 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 for the emergency department,
although applicable to multiple settings, which indicates patient comprehension of such information is low and may
impact post-discharge follow-up care and medication adherence.16
NUMERATOR:
Documentation that all of the following occurred prior to discharge:
 Provision of education to the resident, family, or caregiver
 Evidence that understanding of the education provided was assessed
 An opportunity for the resident to ask questions
DENOMINATOR:
All nursing home residents who are discharged home
EXCLUSIONS:
Residents who:
 Are transferred to an acute care setting, or
 Leave against medical advice, without allowing sufficient time to provide education.
RISK ADJUSTMENT:
None – see exclusions
DEFINITIONS
Caregiver:
A person who provides care and support to the resident.
Effective education: Education that incorporates testing of the resident’s understanding (e.g., use of a teach-back
method).
Patient education:
Includes, at minimum, the reason for the nursing home stay, any changes to medications and the
reason for the change, condition-specific “red flags” that should prompt the resident to seek
medical
attention and whom the resident should call, activity and other limitations, and recommended
follow-up appointments and tests.
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
Safe Transitions Best Practice Measures
NOTES:
Communication with residents should incorporate concepts of health literacy and cultural competence, and should
adhere to interpreter requirements, per state and Federal law.
This best practice includes short-stay residents receiving skilled services, as well as long-stay residents transitioning back
into the community.
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
Nursing homes, including skilled nursing and/or long-term care facilities
Not applicable – all patients
Medical record or electronic audit trail
Practitioner, unit, facility or community (e.g., health system or state)
Process measure
All nursing home residents who are discharged home
MEASURE HISTORY:
This measure was developed by Healthcentric Advisors, the Medicare Quality Improvement Organization for Rhode
Island, using a multi-stage stakeholder consensus process. It has 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 (skilled nursing and/or long-term care) and their
community partners (e.g., PCPs) 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, this measure (and the other Safe Transitions Best Practice Measures for
Nursing Homes) may not be generalizable to other states and regions, but can inform the development of local
standards.
MEASURE INFORMATION:
Lynne Chase
Massachusetts Program Director, Healthcentric Advisors
lchase@healthcentricadvisors.org or 877.904.0057 X3253
CONSULTING SERVICES:
Kara Butler, MBA, MHA
Senior Manager, Corporate Services, Healthcentric Advisors
kbutler@healthcentricadvisors.org or 401.528.3221
MEASURE DEVELOPED:
2009
MEASURE LAST UPDATED:
18 February 2014
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
Safe Transitions Best Practice Measures
MEASURE:
Written discharge instructions provided to residents prior to nursing home discharge
MEASURE SET:
Safe transitions best practice measures for nursing homes (Best Practice #8)
MEASURE DESCRIPTION:
This measure estimates the frequency with which nursing home residents 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.17 Residents discharged home are expected to selfmanage their follow-up, and provision of written discharge instructions ensures that residents and their families have
information to refer to. It may also be helpful to downstream providers, if residents 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 resident, family, or caregiver prior to discharge
DENOMINATOR:
All nursing home residents who are discharged home
EXCLUSIONS:
Residents who:


Are transferred to an acute care setting, or
Leave against medical advice, without allowing sufficient time to provide instructions.
RISK ADJUSTMENT:
None – see exclusions
DEFINITIONS
Caregiver:
A person who provides care and support to the resident.
Discharge instructions: Includes, at minimum, the information provided verbally as part of effective education (the
reason for the nursing home stay, any changes to medications and the reason for the change,
condition-specific “red flags” that should prompt the resident to seek medical attention and
whom the resident should call, activity and other limitations, and recommended follow-up
appointments and tests), as well as nursing home contact information.
Nursing home
contact information:
A phone number that connects discharged residents to a clinician who can
answer questions about their nursing home stay or follow-up care.
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
Safe Transitions Best Practice Measures
NOTES:
This best practice includes short-stay residents receiving skilled services, as well as long-stay residents transitioning back
into the community.
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
Nursing homes, including skilled nursing and/or long-term care facilities
Not applicable – all patients
Medical record or electronic audit trail
Practitioner, unit, facility or community (e.g., health system or state)
Process measure
All nursing home residents who are discharged home
MEASURE HISTORY:
This measure was developed by Healthcentric Advisors, the Medicare Quality Improvement Organization for Rhode
Island, using a multi-stage stakeholder consensus process. It has 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 (skilled nursing and/or long-term care) and their
community partners (e.g., PCPs) 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, this measure (and the other Safe Transitions Best Practice Measures for
Nursing Homes) may not be generalizable to other states and regions, but can inform the development of local
standards.
MEASURE INFORMATION:
Lynne Chase
Massachusetts Program Director, Healthcentric Advisors
lchase@healthcentricadvisors.org or 877.904.0057 X3253
CONSULTING SERVICES:
Kara Butler, MBA, MHA
Senior Manager, Corporate Services, Healthcentric Advisors
kbutler@healthcentricadvisors.org or 401.528.3221
MEASURE DEVELOPED:
2009
MEASURE LAST UPDATED:
18 February 2013
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
Safe Transitions Best Practice Measures
MEASURE:
Follow-up appointment scheduled prior to nursing home discharge
MEASURE SET:
Safe transitions best practice measures for nursing homes (Best Practice #9)
MEASURE DESCRIPTION:
This measure estimates the frequency with which residents have a follow-up appointment scheduled with their primary
care provider (PCP) or a relevant specialist before they leave the nursing home.
Although improved communication between the nursing home and community-based PCPs can help to close knowledge
gaps during the nursing home stay, many PCPs (or specialists, as appropriate) do not fully assume responsibility for
residents discharged from nursing homes until the follow-up appointment.
The follow-up appointment is important for the provider to: 1) assume professional responsibility for patient care, 2)
assess and facilitate adherence to discharge instructions and medications, and 3) provide an opportunity for patients to
ask questions. Scheduling during the nursing home stay ensures that residents leave the nursing home with the date and
time of their follow-up appointments included with their discharge instructions.
NUMERATOR:
Documentation that both of the following occurred prior to discharge:


An outpatient primary care provider (PCP) or specialist visit, as appropriate, was scheduled to occur within 14 days
of the nursing home discharge date (unless timeframe otherwise specified and documented in the medical record),
and
Information about the follow-up appointment was provided to the resident, family, or caregiver
DENOMINATOR:
All nursing home residents who are discharged home
EXCLUSIONS:
Residents who:



Are transferred to an acute care setting,
Leave against medical advice without allowing sufficient time for an appointment to be scheduled, or
Decline to have a follow-up appointment scheduled for any reason.
RISK ADJUSTMENT:
None – see exclusions
DEFINITIONS
Caregiver:
A person who provides care and support to the resident.
Information about the
follow-up appointment:
Date, time, location, and contact information for questions or to reschedule.
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
Safe Transitions Best Practice Measures
NOTES:
Scheduling appointments should involve the resident, family, or caregiver, in order to identify an appointment time that
is feasible for the resident and minimizes the risk of no-shows at the physician office.
If the resident has no known PCP, then this process should include assigning the resident to a PCP and scheduling a new
patient appointment.
This best practice includes short-stay residents receiving skilled services, as well as long-stay residents transitioning back
into the community.
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
Nursing homes, including skilled nursing and/or long-term care facilities
Not applicable – all patients
Medical record or electronic audit trail
Practitioner, unit, facility or community (e.g., health system or state)
Process measure
All nursing home residents, including those receiving skilled services
MEASURE HISTORY:
This measure was developed by Healthcentric Advisors, the Medicare Quality Improvement Organization for Rhode
Island, using a multi-stage stakeholder consensus process. It has 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 (skilled nursing and/or long-term care) and their
community partners (e.g., PCPs) 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, this measure (and the other Safe Transitions Best Practice Measures for
Nursing Homes) may not be generalizable to other states and regions, but can inform the development of local
standards.
MEASURE INFORMATION:
Lynne Chase
Massachusetts Program Director, Healthcentric Advisors
lchase@healthcentricadvisors.org or 877.904.0057 X3253
CONSULTING SERVICES:
Kara Butler, MBA, MHA
Senior Manager, Corporate Services, Healthcentric Advisors
kbutler@healthcentricadvisors.org or 401.528.3221
MEASURE DEVELOPED:
2009
MEASURE LAST UPDATED:
18 February 2014
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
Safe Transitions Best Practice Measures
MEASURE:
Summary clinical information provided to outpatient physician(s) at discharge
MEASURE SET:
Safe transitions best practice measures for nursing homes (Best Practice #10)
MEASURE DESCRIPTION:
This measure estimates the frequency with which nursing homes send summary clinical information about the patient’s
stay to primary care providers (PCPs) and relevant specialists when their patients are discharged from the nursing home.
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.18 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 to the ED. Outpatient physicians also
need this information to understand the rationale for recommended follow-up and medication changes, in order to
facilitate the treatment plan or to modify it.19
NUMERATOR:
Documentation that the following was sent to physician office(s), within 24 hours of resident discharge:



A brief narrative of the nursing home stay,
A medication list, and
Nursing home contact information
DENOMINATOR:
All nursing home residents who are discharged home
EXCLUSIONS:
Residents who:


Are transferred to an acute care setting, or
Do not have an outpatient physician (and declined to have a new patient appointment scheduled).
RISK ADJUSTMENT:
None – see exclusions
DEFINITIONS
Contact information:
A phone number that connects the outpatient physician to nursing home staff who can address
the physician’s question.
Outpatient physician:
The patient’s PCP and relevant specialists, if applicable.
Sent:
Transmitted from the nursing home to the outpatient physician office via fax, email or other
electronic means.
NOTES:
This best practice includes short-stay residents receiving skilled services, as well as long-stay residents transitioning back
into the community.
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
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
Nursing homes, including skilled nursing and/or long-term care facilities
Not applicable – all patients
Medical record or electronic audit trail
Practitioner, unit, facility or community (e.g., health system or state)
Process measure
All nursing home residents who are discharged home
MEASURE HISTORY:
This measure was developed by Healthcentric Advisors, the Medicare Quality Improvement Organization for Rhode
Island, using a multi-stage stakeholder consensus process. It has 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 (skilled nursing and/or long-term care) and their
community partners (e.g., PCPs) 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, this measure (and the other Safe Transitions Best Practice Measures for
Nursing Homes) may not be generalizable to other states and regions, but can inform the development of local
standards.
MEASURE INFORMATION:
Lynne Chase
Massachusetts Program Director, Healthcentric Advisors
lchase@healthcentricadvisors.org or 877.904.0057 X3253
CONSULTING SERVICES:
Kara Butler, MBA, MHA
Senior Manager, Corporate Services, Healthcentric Advisors
kbutler@healthcentricadvisors.org or 401.528.3221
MEASURE DEVELOPED:
2009
MEASURE LAST UPDATED:
18 February 2013
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
Safe Transitions Best Practice Measures
MEASURE:
Residents have access to medication after nursing home discharge
MEASURE SET:
Safe transitions best practice measures for nursing homes (Best Practice #11)
MEASURE DESCRIPTION:
This measure estimates the frequency with which nursing homes facilitate residents’ access to needed medications after
discharge.
By facilitating residents’ access to medications after nursing home discharge, nursing homes may prevent adverse
effects due to residents missing medication doses in the time period between nursing home discharge and the first
follow-up appointment with an outpatient physician. Many outpatient physicians may be unaware of medication
changes that occurred while their patient was hospitalized or in a nursing home, and they may be reluctant to prescribe
a medication not in their records without seeing the patient first.20 Additionally, if residents do not have an adequate
supply of medications after nursing home discharge, they may revert to prior prescriptions still on file at their pharmacy
or old medications and dosing regimens which may no longer be medically indicated or safe.
NUMERATOR:
Documentation that either of the following occurred prior to nursing home discharge:
 The resident received enough medications to last until the end of the intended treatment course or until the first
outpatient follow-up appointment, or
 The resident received prescriptions for a 30-day supply (or to the end of the treatment course, if sooner) of all
medications
DENOMINATOR:
All nursing home residents who are discharged home
EXCLUSIONS:
Residents who:



Are transferred to an acute care setting,
Leave against medical advice without allowing sufficient time to provide medications or prescriptions, or
Do not take any medications.
RISK ADJUSTMENT:
None – see exclusions
DEFINITIONS
None
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
Safe Transitions Best Practice Measures
NOTES:
It is not intended that nursing homes provide more medications than is their standard practice, but instead that they
help residents avoid missing medication doses between nursing home discharge and resumption of care by an
outpatient physician.
If a resident has been consistently receiving a medication that can result in physical dependency (e.g., opioids,
benzodiazepines) and the nursing home does not plan to provide this medication or a prescription after discharge, the
nursing home will need to 1) taper this medication off prior to the resident’s discharge or 2) arrange for an outpatient
physician to immediately assume prescribing responsibilities.
This best practice includes short-stay residents receiving skilled services, as well as long-stay residents transitioning back
into the community.
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
Ensuring that each person and family are engaged as partners in their care
Quality improvement with benchmarking; contracting; pay for performance
Nursing homes, including skilled nursing and/or long-term care facilities
Not applicable – all patients
Medical record or electronic audit trail
Practitioner, unit, facility or community (e.g., health system or state)
Process measure
All nursing home residents who are discharged home
MEASURE HISTORY:
This measure was developed by Healthcentric Advisors, the Medicare Quality Improvement Organization for Rhode
Island, using a multi-stage stakeholder consensus process. It has 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 (skilled nursing and/or long-term care) and their
community partners (e.g., PCPs) 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, this measure (and the other Safe Transitions Best Practice Measures for
Nursing Homes) may not be generalizable to other states and regions, but can inform the development of local
standards.
MEASURE INFORMATION:
Lynne Chase
Massachusetts Program Director, Healthcentric Advisors
lchase@healthcentricadvisors.org or 877.904.0057 X3253
CONSULTING SERVICES:
Kara Butler, MBA, MHA
Senior Manager, Corporate Services, Healthcentric Advisors
kbutler@healthcentricadvisors.org or 401.528.3221
MEASURE DEVELOPED:
2009
MEASURE LAST UPDATED:
18 February 2014
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
Safe Transitions Best Practice Measures
1
Kaiser Family Foundation. To Hospitalize or Not to Hospitalize? Medical Care for Long-Term Care Facility Residents. October 2010. Available:
http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8110.pdf, 11 November 2013.
2
Harvell, J., Dougherty, M. Opportunities for Engaging Long Term and Post Acute Care Providers in Health Information Exchange Activities: Exchanging Interoperable Patient Assessment
Information. Available at: http://aspe.hhs.gov/daltcp/reports/2011/StratEng.pdf, 11 November 2013.
3
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
Gillespie SM, Gleason LJ, Karuza J, Shah MN. Health care providers’ opinions on communication between nursing homes and emergency departments. J Am Med Dir Assoc. 2010;11:204–10.
5
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
Gillespie SM, Gleason LJ, Karuza J, Shah MN. Health care providers’ opinions on communication between nursing homes and emergency departments. J Am Med Dir Assoc. 2010;11:204–10.
7
Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Hospital‐based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172(14):1057.
8
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.
9
Caglar S, Henneman PL, Blank FS, Smithline HA, Henneman EA. Emergency department medication lists are not accurate. J Emerg Med. 2011; 40: 613‐616.
10
Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005; 165(16):1842-7.
11
Leonard M, Graham S, Bonacum D. The Human Factor: The Critical Importance of Effective Teamwork and Communication in Providing Safe Care. Quality and Safety in Health Care.
2004;13:i85–i90
12
Kaiser Family Foundation. To Hospitalize or Not to Hospitalize? Medical Care for Long-Term Care Facility Residents. October 2010. Available:
http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8110.pdf, 11 November 2013.
13
American Medical Directors Association (AMDA). Available: http://www.amda.com/tools/clinical/toccpg.pdf, 20 Nov 2011.
14
Rebecca L. Sudore and Terri R. Fried. Redefining the “Planning” in Advance Care Planning: Preparing for End-of-Life Decision Making. Ann Intern Med. 2010 August 17; 153(4): 256–261.
15
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.
16
Samuels-Kalow ME, Stack AM, Porter SC. Effective discharge communication in the emergency department. Ann Emerg Med. 2012; 60(2):152- 9.
17
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 MedicineSociety 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
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.
19
American Medical Directors Association (AMDA). Improving Care Transitions From the Nursing Facility to a Community-Based Setting.
http://www.amda.com/governance/whitepapers/transitions_of_care.cfm, 13 Feb 2014.
20
American Medical Directors Association (AMDA). Improving Care Transitions From the Nursing Facility to a Community-Based Setting.
http://www.amda.com/governance/whitepapers/transitions_of_care.cfm, 13 Feb 2014.
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
Safe Transitions Best Practice Measures
SELECTED SOURCES:
Safe transitions best practice measures for nursing homes
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) and obtaining input (measure content and feasibility) and endorsement from the targeted provider group
(nursing homes) 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
Nursing Homes
American Medical
Directors Association
(AMDA), 20111
Nursing
home
Clinical practice guidelines for care
transitions in the long-term care setting
These guidelines outline the scope of the problem, barriers to
care transitions, cross setting issues and a seven step process
for implementation care transitions program.
American Medical
Directors Association
(AMDA), 20102
Nursing
Home
Identifies issues with care transitions from
the nursing facility to a community-based
setting and presents recommendations for
improvement
Recommendations for this setting include identifying
responsibility, improve information provision at transition,
medication reconciliation, and a patient centered approach.
Review of emergency department
medication lists
Emergency department medication lists are not always
accurate and measures are needed to support ED providers in
obtaining and communicating accurate medication histories.
4
Provided a transitions coach to help
improve patient education and selfmanagement 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.
4,7-9
Calgar et al., 20113
Coleman et al., 20094
ED
Hospital
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
2-4,6,7,10
10,11
Safe Transitions Best Practice Measures
Author, Year
Discharge
Setting
Intervention or Observation
Findings
Related Best
Practice
Measure(s) for
Nursing Homes
Gillespie et al., 20105
ED and
nursing
home
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.
Harvell et al., 20116
Multiple
Importance of health information
exchange in improving transitions for long
term care patients
Quality of care and care coordination will benefit from the
adoption of health information technology and health
information exchanges by long term post-acute providers.
INTERACT II, 2011 7
Nursing
home
Program to reduce frequency of avoidable
transfers of skilled nursing patients to
acute care hospitals
Some acute care transfers are avoidable through the use of
clinical, communication and advance care planning tools to
identify, evaluate and communicate changes in resident status.
2,5,6
Jack et al., 20098
Hospital
Multifaceted package of discharge services
Use of a nurse discharge advocate during hospitalization and a
pharmacist post‐discharge decreased ED visits and
readmissions.
2,4,8,9,11
Joint Commission,
20139
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.
Kaiser Family
Foundation, 2010.10
Nursing
home
Report developed from interviews with
medical professionals, long-term care
facility staff and family members on how
long-term care decisions are made
Individuals interviewed agree that despite the severe needs of
long-term care patients, hospitalizations are often too routine
and preventable, indicating the need for a balance between
providing appropriate medical care for these patients and
avoiding unnecessary trips to the hospital.
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
2,3
1
4,7,8
4,6
Safe Transitions Best Practice Measures
Author, Year
Leonard et al., 200411
Mills and McGuffie,
201012
Discharge
Setting
Multiple
ED
Intervention or Observation
Findings
Related Best
Practice
Measure(s) for
Nursing Homes
Review of the role and importance of
effective teamwork and communication in
care
Failures in communication, which lead to unanticipated
adverse events, can be prevented through effected teamwork
and communication, as well as through the incorporation of
standardized communication tools (i.e SBAR).
5
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.
4
Mueller et al., 201213
Multiple
Summarizes available evidence and
effective methods for medication
reconciliation process
Found that studies comparing the effect of medication
reconciliation processes on clinical outcomes are rare. The
available evidence suggests a focus on pharmacy staff and high
risk patients is important.
4
National Transitions of
Care Coalition, 201114
Multiple
Bundle of seven essential interventions
applicable for any setting
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.
1-11
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
Safe Transitions Best Practice Measures
National Quality
Forum, 201015
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.
2-4,7-11
Nursing Home Quality
Campaign16
Nursing
home
Campaign to assist nursing homes in
achieving high quality of care for residents
Demonstrates its process and clinical outcome goals assist
nursing homes in achieving high quality care through reported
quality measures.
6
Sudore and Fried,
2010.17
Multiple
Discussion of the objective of advance
care planning , having patients make
treatment decisions in advance of serious
illness so clinicians can attempt to provide
care consistent with their goals.
The authors present that the main objective of advance care
planning should be to prepare patients and their families to
work with their clinicians to make the best possible in-themoment medical decisions, instead of a focus on recording
advance directives.
6
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
Developed consensus policy statement
about care transitions
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.
Samuels-Kalow et al.,
201218
Snow et al., 200919
ED
Multiple
KEY:
1. Interventions implemented for residents at highest risk for unplanned transfer
2. Clinical information sent with emergency department referrals
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Providence, RI  Woburn, MA  Brunswick, ME
2,3,7,8,10
Safe Transitions Best Practice Measures
3.
4.
5.
6.
7.
8.
9.
10.
11.
Real-time verbal information provided to emergency department or hospital clinicians, if needed
Medication reconciliation completed after emergency department or hospital discharge
Structured communication used for clinical questions to physicians
End-of-life care discussed with residents
Effective education provided to residents prior to nursing home discharge
Written discharge instructions provided to residents prior to nursing home discharge
Follow-up appointment scheduled prior to nursing home discharge
Summary clinical information provided to outpatient physician(s) at discharge
Residents have access to medication after nursing home discharge
REFERENCES:
1
American Medical Directors Association (AMDA). Transitions of Care in the Long-Term Care Continuum Available: http://www.amda.com/tools/clinical/toccpg.pdf,
20 Nov 2011.
2
American Medical Directors Association (AMDA). Improving Care Transitions From the Nursing Facility to a Community-Based Setting.
http://www.amda.com/governance/whitepapers/transitions_of_care.cfm, 13 Feb 2014.
3
Caglar S, Henneman PL, Blank FS, Smithline HA, Henneman EA. Emergency department medication lists are not accurate. J Emerg Med. 2011; 40: 613‐616.
4
Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. Sep 12 2005;165(16):18421847.
5
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.
6
Harvell, J., Dougherty, M. Opportunities for Engaging Long Term and Post Acute Care Providers in Health Information Exchange Activities: Exchanging
Interoperable Patient Assessment Information. Dec 2011. Available at: http://aspe.hhs.gov/daltcp/reports/2011/StratEng.pdf, 11 November 2013.
7
INTERACT II. Available: http://www.interact2.net/index.aspx, 13 Sep 2011.
8
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.
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME
Safe Transitions Best Practice Measures
9
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.
10
Kaiser Family Foundation. To Hospitalize or Not to Hospitalize? Medical Care for Long-Term Care Facility Residents. October 2010. Available:
http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8110.pdf, 11 November 2013.
11
Leonard M, Graham S, Bonacum D. The Human Factor: The Critical Importance of Effective Teamwork and Communication in Providing Safe Care. Quality and
Safety in Health Care. 2004;13:i85–i90
12
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.
13
Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Hospital‐based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172(14):1057.
14
National Transitions of Care Coalition. Care Transition Bundle Seven Essential Intervention Categories. 2011. Available: http://www.ntocc.org/Toolbox/ Accessed
Oct 29, 2013.
15
National Quality Forum. Safe Practices. 2010. Available: http://www.qualityforum.org/Projects/Safe_Practices_2010.aspx, 11 Apr 2013.
16
Nursing Home Quality Campaign. Available: http://www.nhqualitycampaign.org/star_index.aspx?controls=welcome, 13 Sep 2011.
17
Rebecca L. Sudore and Terri R. Fried. Redefining the “Planning” in Advance Care Planning: Preparing for End-of-Life Decision Making. Ann Intern Med. 2010
August 17; 153(4): 256–261.
18
Samuels-Kalow ME, Stack AM, Porter SC. Effective discharge communication in the emergency department. Ann Emerg Med. 2012; 60(2):152-9.
19
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.
MEASURE INFORMATION:
CONSULTING SERVICES:
Lynne Chase
Massachusetts Program Director, Healthcentric Advisors
lchase@healthcentricadvisors.org or 877.904.0057 X3253
Kara Butler, MBA, MHA
Senior Manager, Corporate Services, Healthcentric Advisors
kbutler@healthcentricadvisors.org or 401.528.3221
LAST UPDATED:
18 February 2014
www.healthcentricadvisors.org
Providence, RI  Woburn, MA  Brunswick, ME