Bundling: Wrapping in Quality

(Post Six in a series)

By Joanne Conroy, MD

As our bundling group begins the journey through the currently available quality measures across inpatient and post-acute settings, the comments and revelations have been interesting:

1. There is a lot of enthusiasm for new measures that assess outcome more accurately.

However, the group is composed of realists who understand that integrating measures that are not validated or tested is foolish.

2. We realize how little we know about post-acute measures of quality, and needed education from the group members who have been living in this space. Thank you U Mass, Sinai, and Einstein!

Here’s a summary of where the group is heading. They have agreed to important quality and safety measures that cross all disease states including:

– HCAHPS: Hospital Care Quality from the Consumer Perspective Survey, a tool that measures patients’ care experiences

– Discharge instructions that clearly define what should happen post-discharge to ensure care continuity; including physician follow-up, expected symptoms during recovery, and symptoms that should result in a return to the doctor’s office or emergency room

– 30-Day Mortality: monitors how many patients die within 30 days of discharge from the hospital

– 30-Day All-Cause Readmission: how many patients are readmitted to the hospital for any reason within 30 days of discharge

– Medication reconciliation: Part of the Meaningful Use requirement that stipulates a reconfirmation of the patient’s medication regimen by phone call or home visit; intended to confirm that new prescriptions have been filled and patient is taking them

– Follow-up with provider within seven days: Another Meaningful Use requirement; to answer any patient or caregiver questions and to confirm that the patient is on the expected recovery course.

The bundling group has identified important quality measures for each episode that are specific to that condition:

– Surgical Care Improvement Project (SCIP) Measures focus on reducing surgical infections complication rates through measurement and reporting of six infection-prevention process-of-care measures

– 30-Day specific and all-cause mortality and readmission measures

– Stroke measures aligned with Get with the Guidelines, an in-hospital program designed to improve treatment for patients who have had an acute stroke. The guidelines focus on quick diagnosis and treatment using interventions or thrombolytics after a stroke; and actions to prevent future strokes.

The group has had some great discussion about how to measure Care Transitions and functional status post-discharge, and has investigated several tools including the three-item CTM measure, CMS’s CARE tool, SF-12, and leveraging the post-acute rehab reporting requirements currently in place for pressure ulcers, CLABSI (Central Line-Associated Bloodstream Infection) and CAUTI (Catheter-Associated Urinary Tract Infections). Many of these are not currently in use by CMS for public reporting but are in the pipeline or important for institutional feedback.

The group is also examining a short health survey to determine functional status called SF 12, and has looked at the Vulnerable Elders Survey (VES-13), which more explicitly assesses the activities of daily living and can quantify changes.

Our internal experts have had a number of conversations about assessing the functional status issue; they wonder if we should use the CARE tool for the conditions where it’s appropriate to measure functional status. The tool, which is long and resource-intensive, is being required for LTACs starting in October. There is a good possibility it might be coming our way. If we include it, we will add some kind of caveat about including it for reporting but not yet for performance. The same holds true for the care transition measure. It was included in the Measures Application Partnership report (National Quality Forum) so it will likely be coming our way.

We are having a session focusing just on Model 3, which will probably inform the post-acute activity in Model 2. Some of our members have been approached by post-acute providers who want to be participants in their bundling application! As long as the models do not overlap—a Model 4 participant partners with a Model 3 participant—this could lead to positive collaboration.

—Joanne Conroy, MD, is Chief Health Care Officer at the Association of American Medical Colleges. She can be reached at jconroy@aamc.org. Follow her on Twitter @joanneconroymd.