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Massachusetts state leaders believe that poor communication and a lack of clear accountability for patients among multiple providers lead to medical errors, waste, and duplication. Adverse events often occur during care transitions, most often with complex, chronically ill, and vulnerable patients. Such events can result from failure to communicate critical information related to a patient’s medical care, safety, medications, advance directives, in-home support services, and social situation. Failure to identify issues in such areas as health literacy and cultural preferences may also lead to higher rates of hospitalization, particularly in vulnerable populations. The result is high expenditures for the chronically ill, driven primarily by hospital admissions and readmissions.

We envision a future in which interdisciplinary teams deliver safe, effective, and timely care that is culturally and linguistically appropriate—within and across settings. This vision calls for care that is organized around regions and communities; that is delivered by integrated systems coordinated across settings; and in which the flow of patient information is seamless and secure among all of a patient’s providers, insurers, and patients themselves. To accomplish this transformational change, the Massachusetts healthcare community will require collaboration and effective partnerships focused on the creation of a patient-centered care model delivered within learning healthcare systems and encompassing the entire continuum of care. This paper describes the process undertaken by the Commonwealth of Massa­ chusetts to identify and quantify issues associated with care transitions, and to develop and implement a statewide strategic plan for beginning to address those issues. This strategic plan is designed to delineate actionable steps to help the Massachusetts healthcare community realize the vision of integrated, high-value, coordinated, and efficient healthcare delivery.

Background and Significance

Health care in the United States has evolved into a complex array of settings, providers, payers, and procedures. Settings of care include hospitals; subacute and postacute nursing facilities; the patient’s home; primary and specialty care offices; community health centers; rehab facilities; home health agencies; hospice; long-term care facilities; and other institutional, ambulatory, and ancillary care providers. In each setting, multiple clinicians care for each patient, sometimes independently and at other times as part of an interdisciplinary team. Figure 8-2 depicts the interdependencies among many different organizations and settings involved in realizing this vision in Massachusetts.

Improving care transitions has the potential to save lives, reduce adverse events and disability due to gaps or omissions in care, and reduce unnecessary costs. Several national clinical and policy models were

ing continuity, coordinating care, and maintaining relationships. The model is implemented by a single advanced practice nurse using evidence-based protocols and with a focus on long-term outcomes. The model was initially tested in a randomized controlled trial of 276 older adults at the University of Pennsylvania Hospital (Naylor et al., 2004). It resulted in fewer hospital readmissions, fewer total days rehospitalized, lower readmission­ charges, and lower charges for healthcare services after discharge.

The final model emerged from a collaboration among the American College of Physicians, the Society of Hospital Medicine, the American Geriatric­ Society, the American College of Emergency Physicians, and the Society for Academic Emergency Medicine to develop consensus standards to address quality gaps in care transitions. The Transitions of Care Consensus Conference, held in fall-winter 2006, developed several principles and clinical standards for care transitions: accountability, communication of treatment plans and follow-up expectations, timely feedback, involvement of the patient­ and family, respect for the hub of coordination of care, the patient’s ability to identify a medical home, patients knowing who is responsible at every point along the transition, national standards for transitions in care, and standardized metrics for continuous quality improvement and accountability (NTOCC, 2009; Snow et al., 2009).

Creating the Plan

Although efforts to improve care transitions had been ongoing for some time, those efforts were fragmented and uncoordinated. About 3 years ago, a small group of clinicians, healthcare administrators, and government agency staff, coordinated by the Massachusetts Health Data Consortium and Massachusetts Senior Care Foundation, came together to discuss gaps in such efforts and how to disseminate individual work more broadly. That group grew to more than 100 stakeholders and is now known as the Care Transitions Forum, representing a community of interest that meets quarterly to share best practices and provide mentorship to institutions and organizations across the state. Concurrently, senior policy staff from the Massachusetts Executive Office of Health and Human Services had been developing statewide initiatives around patient-centered medical homes and accountable care organizations. They determined that none of these reforms would attain maximum effectiveness unless coordination across care settings was improved. The policy staff members were active participants in the Care Transitions Forum, and with the Secretary’s approval, the idea of creating a strategic plan was put forth. The development work was a learning process involving public and private stakeholders from across the Commonwealth. A working group composed of senior administration officials working together with the policy community began by reviewing the

included patients, families, and advocates in the development and review of each stage of the plan. Still, the first few drafts appeared to lack a strong enough patient focus, so an unfolding case study was added to the document. This enabled us to tell a story from the patient’s point of view, and put a very real face on the problem of unsafe care transitions and rehospitalizations.

Another objective was to build consensus among the many stakeholders­ as to the most important care transition principles; to this end, it was necessary to get people to agree to work together outside of their individual institutions for the good of state health policy. For example, many institutions have their own patient transfer form or process. Numerous forms, very similar but each somewhat unique, exist. To improve consistency and institute a standardized, evidence-based process, each institution must agree to give up some customization so that a unified form and process can be adopted statewide. Bringing stakeholders in early, obtaining their input, and listening to their concerns have been essential parts of our process. We are currently moving forward with final development and deployment of our statewide resident transfer form, which we anticipate will be posted on the Massachusetts Department of Public Health website in the next few months.

A third objective was to include guidance addressing accountability between sending and receiving institutions. When a patient leaves one setting of care, someone must be prepared to receive that patient in the next setting of care. Longitudinal responsibility rests with the sending provider until the receiving provider has acknowledged and accepted the patient. While we anticipated that hospitals and physicians would be resistant to this concept, they accepted the significance of this component of care transitions and the need to address this difficult problem. Ongoing discussions in 22 communities are currently under way as part of the State Action to Avoid Rehospitalizations project, supported by a grant from the Commonwealth Fund.

Measurement

As a learning healthcare system and state, we must be able to measure performance improvement in care transitions. Put simply, how will we know a safe and effective transition when we see it?

The Massachusetts strategic plan for care transitions outlines a strategy for tracking progress and measuring successes and challenges. Performance measurement is essential if the best practices and lessons learned from state demonstrations and national research and care models are to be implemented effectively on a statewide basis. The measures described in the plan have been endorsed by recognized national and state panels of experts. The

plan presents a menu of options for measurement, and proposes that the selection process involve providers, payers, and patients/advocates to ensure that measurement is balanced and reflects the essential roles of providers, insurers, and patients in improving the process.

The National Quality Forum has endorsed several measures for care transitions: the three-item Care Transitions Measure, the 30-day all-cause risk-standardized readmission rate following hospitalization for heart failure developed by the Centers for Medicare & Medicaid Services (CMS), the CMS 30-day all-cause risk-standardized readmission rate following hospitalization for acute myocardial infarction, the CMS 30-day all-cause riskstandardized readmission rate following hospitalization for ­pneumonia, and the all-cause readmission index (NQF, 2007).

Certain process measures are linked to successful outcomes: the timely transfer of information across settings and professionals involved in care transitions, the effective coordination of transitions across settings and professionals, the timely delivery of care, improvement in patient understanding of and adherence to the treatment plan, improvement in patient awareness of emergency provider contact information, and improvement in patient engagement in care (ABIM, 2009). Ongoing work to refine measures is part of the Massachusetts strategic plan.

Dissemination and Next Steps

In his book Agendas, Alternatives, and Public Policies, John Kingdon explains how policy issues rise and fall on public agendas (Kingdon, 2003). He describes three independent streams of activities—problems, policies, and politics—that must occur before effective decision making takes place in government. For a problem to be identified, there must at some point in time be agreement that solutions exist. Policies are generated by specialists, staffers, academics, and interest groups. The creation of the strategic plan accomplished these first two activities. The third required careful vetting of the plan with interested parties. The most prominent of these was the Health Care Quality and Cost Council, which had been established under Massachusetts’ landmark healthcare reform law in 2006.

With the Kingdon policy hurdles passed, Massachusetts has now moved into the implementation phase, with workgroups already engaged in the refinement and deployment of a statewide interfacility transfer form and process, as well as state surveyor education around effective care transitions. As more cross-continuum teams are established in more communities, Massachusetts will continue to evolve as a learning health system at the state level.

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