Excellence in Transitional Care of Older Adults and Pay-for-Performance: Perspectives of Health Care Professionals.

UNLABELLED: Article-at-a-Glance Background: Care transitions across health care settings are common and can result in adverse outcomes for older adults. Few studies have examined health care professionals' perspectives on important process measures or pay-for-performance (P4P) strategies related to transitional care. A study was conducted to characterize health care professionals' perspectives on (1) successful transitional care of older adults (age 65 years and older), (2) suggestions for improvement, and (3) P4P strategies related to transitional care. METHODS: In a qualitative study, one-hour semistructured in-depth interviews were conducted in an acute care hospital, a skilled nursing facility, two community-based primary care practices, and one home health care agency with 20 health care professionals (18 physicians and 2 home health care administrators) with direct experience in care transitions of older adults and who were likely to be affected by P4P strategies. RESULTS: Findings were organized into three thematic domains: (1) components and markers of effective transitional care, (2) difficulties in design and implementation of P4P strategies, and (3) health care professionals' concerns and unmet needs related to delivering optimal care during transitions. A conceptual framework was developed on the basis of the findings to guide design and implementation of P4P strategies for improving transitional care. CONCLUSION: In characterizing health care professionals' perspectives, specific care processes to target, challenges to address in the design of P4P strategies, and unmet needs to consider regarding education and feedback for health care professionals were described. Future investigations could evaluate whether performance targets, educational interventions, and implementation strategies based on this conceptual framework improve quality of transitional care.

Clinician roles and responsibilities during care transitions of older adults.

OBJECTIVES: To identify the perceived roles and responsibilities of clinicians during care transitions of older adults. DESIGN: Qualitative study involving 1-hour in-depth semistructured interviews. Audiotapes of interviews were transcribed, coded, and analyzed, and themes and subthemes were generated. SETTING: An acute care hospital, a skilled nursing facility, two community-based outpatient practices, and one home healthcare agency. PARTICIPANTS: Forty healthcare professionals directly involved in care transitions of older adults (18 physicians, 11 home healthcare administrative and field staff, four social workers, three nurse practitioners, three physician assistants, and one hospital case manager). MEASUREMENTS: Perspectives of healthcare professionals regarding clinicians' roles and responsibilities during care transitions were examined and described. RESULTS: Content analysis revealed several themes: components of clinicians' roles during care transitions; congruence between self- and others' perceived ideal roles but incongruence between ideal and routine roles; ambiguity in accountability in the postdischarge period; factors prompting clinicians to act closer to ideal roles; and barriers to performing ideal roles. A conceptual framework was created to summarize clinicians' roles during care transitions. CONCLUSION: This study reports differences between what healthcare professionals perceive as ideal roles of clinicians during care transitions and what clinicians actually do routinely. Certain patient and clinician factors prompt clinicians to act closer to the ideal roles. Multiple barriers interfere with consistent practice of ideal roles. Future investigations could evaluate interventions targeting various components of the conceptual framework and relevant outcomes.

A validated value-based model to improve hospital-wide perioperative outcomes: adaptability to combined medical/surgical inpatient cohorts.

OBJECTIVES: Authors hypothesized that building safe hospital systems to improve value-based surgical outcomes is predicated on workflow redesign for dynamic risk stratification, coupled with "real-time" mitigation of risk. We developed a comanagement model for hospitalized surgical cohort, and determined whether this iterative process redesign for surgery will be adaptable to disparate hospital systems and will be beneficial for combined medical/surgical adult inpatients. CONTEXT: Concerns about preventable harm in hospitalized patients have generated a plethora of both, process-driven and outcome-based strategies in US Healthcare. Although comparison between hospitals is a common mechanism to drive quality, other innovative approaches are needed for real-time risk mitigation to improve outcomes. METHODS: Prospective implementation of Surgical Continuum of Care (SCoC) model in hospitals initially for surgery patients; subsequently Continuum of Care (CoC) for medical/surgical population. Redesign of hospital care delivery model: patient cohorting, floor-based team building, and intensivist/hospitalist staffing of progressive care unit (PCU). Work flow redesign for clinical effectiveness: multidisciplinary team rounds, acuity stratified care rounding based on dynamic risk assessment into a novel HAWK (high risk)/DOVE (low risk) patient grouping, intensivist/hospitalist comanagement of surgical patients, and targeted response. STUDY: Pre- and postintervention with concurrent cohort control design. SETTING: Academic medical centers for SCoC and integrated health system hospital for CoC. PATIENT GROUPS: SCoC Pilot Study-Campus A: Preintervention control group 1998-2000, Intervention Group 2001-2004; Campus B: Comparator Control Group 1998-2004. SCoC Validation Study-Campus C: Preintervention Group 2001-2005; Intervention Group 2006-2008. CoC Study-Campus D: Hospital-wide Group 2009. METRICS: Mortality, length of stay (LOS): overall, surgical intensive care unit and PCU, readmission rates, and cost. Case mix index for risk adjustment. RESULTS: Total >100,000 admissions. There was a significant reduction in overall surgical mortality in both, pilot (P < 0.002) and validation (P < 0.02) SCoC studies and overall hospital mortality in the medical/surgical CoC study (risk-adjusted mortality index progressively declined in CoC study from 1.16 pre-CoC to 0.77 six months post-CoC implementation; significant at 75% confidence level). Case mix index was unchanged during study period in each campus. Nested study in validation cohort of hospital-wide versus surgery alone (observed/expected mortality index) demonstrated significant benefit to SCoC in intervention group. The mortality benefit was primarily derived from risk-stratified rounding and actively managing risk prone population in the PCU. Surgical intensive care unit, PCU, and total hospital patient-days significantly decreased in SCoC pilot study (P < 0.05), reflecting enhanced throughput. LOS reduction benefit persisted in SCoC validation and CoC studies. In addition to decreased LOS, cost savings were in PCU (range, $851,511-2,007,388) and top diagnosis-related groups, for example, $452 K/yr for diagnosis-related group 148. CONCLUSIONS: SCoC is patient-centered, outcomes-driven, value-based approach for hospital-wide surgical patient safety. The principles of this value paradigm are adaptable to other hospitals as demonstrated in our longitudinal study in 3 hospital systems, and the initial experience of CoC suggests that this model will have benefit beyond surgical hospital cohort.

Systematic review: the value of the periodic health evaluation.

BACKGROUND: The periodic health evaluation (PHE) has been a fundamental part of medical practice for decades despite a lack of consensus on its value. PURPOSE: To synthesize the evidence on benefits and harms of the PHE. DATA SOURCES: Electronic searches of such databases as MEDLINE and the Cochrane Library, review of reference lists, and hand- searching of journals through September 2006. STUDY SELECTION: Studies (English-language only) assessing the delivery of preventive services, clinical outcomes, and costs among patients receiving the PHE versus those receiving usual care. DATA EXTRACTION: Study design and settings, descriptions of the PHE, and clinical outcomes associated with the PHE. DATA SYNTHESIS: The best available evidence assessing benefits or harms of the PHE consisted of 21 studies published from 1973 to 2004. The PHE had a consistently beneficial association with patient receipt of gynecologic examinations and Papanicolaou smears, cholesterol screening, and fecal occult blood testing. The PHE also had a beneficial effect on patient "worry" in 1 randomized, controlled trial but had mixed effects on other clinical outcomes and costs. LIMITATIONS: Descriptions of the PHE and outcomes were heterogeneous. Some trials were performed before U.S. Preventive Services Task Force guidelines were disseminated, limiting their applicability to modern practice. CONCLUSIONS: Evidence suggests that the PHE improves delivery of some recommended preventive services and may lessen patient worry. Although additional research is needed to clarify the long-term benefits, harms, and costs of receiving the PHE, evidence of benefits in this study justifies implementation of the PHE in clinical practice.

Value of the periodic health evaluation.

OBJECTIVES: To systematically review evidence on definitions of the periodic health evaluation (PHE), its associated benefits and harms, and system-level interventions to improve its delivery. DATA SOURCES: Electronic searches in MEDLINE, and other databases; hand searching of 24 journals and bibliographies through February 2006. REVIEW METHODS: Paired investigators abstracted data and judged study quality using standard criteria. We reported effect sizes for mean differences and proportions in randomized controlled trials (RCTs). We adapted GRADE Working Group criteria to assess quantity, quality and consistency of the best evidence pertaining to each outcome, assigning grades of "high," "medium," "low," or "very low." RESULTS: Among 36 identified studies (11 RCTs), definitions of the PHE varied widely. In studies assessing benefits, the PHE consistently improved (over usual care) the delivery/receipt of the gynecological exam/Pap smear (2 RCTs, small effect (Cohen's d (95% confidence interval (CI)):0.07 (0.07,0.07)) to large effect (Cohen's d (CI):1.71 (1.69, 1.73)), strength and consistency graded "high"); cholesterol screening (1 RCT, small effect (Cohen's d (CI):0.02 (0.00,0.04)) with large associations in 4 observational studies, graded "medium"); fecal occult blood testing (2 RCTs, large effects (Cohen's d (CI): 1.19 (1.17, 1.21) and 1.07 (1.05, 1.08)), graded "high"). Effects of the PHE were mixed among studies assessing delivery/receipt of counseling (graded "low"), immunizations (graded "medium"), and mammography (graded "low"). In one RCT, the PHE led to a smaller increase in patient "worry" (13%) compared to usual care (23%) (graded "medium"). The PHE had mixed effects on serum cholesterol (graded "low"), blood pressure, body mass index, disease detection, health habits and health status (graded "medium"), hospitalization (graded "high"), and costs, disability, and mortality (graded "medium"). No studies assessed harms. Delivery of the PHE was improved by scheduling of appointments for PHE (1 RCT, medium effects (Cohen's d (CI): 0.69 (0.68, 0.70)) and offering a free PHE (1 non-RCT, 22% increase) (graded "medium"). CONCLUSIONS: The evidence suggests delivery of some recommended preventive services are improved by the PHE and may be more directly affected by the PHE than intermediate or long-term clinical outcomes and costs. Descriptions of the PHE and outcomes were heterogeneous, and some trials were performed before dissemination of recommendations by the U.S. Preventive Services Task Force, limiting interpretations of findings. Efforts are needed to clarify the long-term benefits of receiving multiple preventive services in the context of the PHE. Future studies assessing the PHE should incorporate diverse populations, carefully define comparisons to "usual care," and comprehensively assess intermediate outcomes, harms, and costs.