Transitions of Care (TOC) Assessment and Implementation Tool Kit Introduction ACMA recognizes that improving care transition processes is a difficult journey, whether you are a single care entity or a large multi-system. Leveraging the Transition of Care Standards and utilizing the TOC Assessment will promote improved organizational and patient outcomes. The TOC Standards provide a common framework for effective, high quality and efficient care transitions in all health care settings. The TOC Standards, when combined with the organizational assessment, help organizations assess, quantify, and identify opportunities around care transition processes applied across any care setting. The TOC website provides a broad source of TOC-sensitive quality measures to guide data collection, which is especially important in value-based care models. Building and maintaining health care relationships are essential for ensuring smooth transitions across the continuum. Interoperability is fundamental to supporting the bidirectional communication essential to smooth care transitions. Since the release of the TOC Standards in early 2019, ACMA has tested the applicability of the standards, consensus measures and assessment tool in two phases of the project. ©2021 American Case Management Association www.acmaweb.org 1
2019: Phase one Two organizations representing post-acute settings were recruited by members of the TOC executive steering committee. They each identified an improvement opportunity and successfully implemented one or more TOC standards and leveraged at least one consensus measure during a 12-week timeframe. To read about these pilot organization projects, review the case studies on the TOC website: https://transitionsofcare.org/implementation/pilot-results/ 2020: Phase two ACMA was now ready to evaluate TOC pre- and post-assessment data and convened six organizations to engage in a 6-month Learning Collaborative. Each organization completed a charter that identified the team members, Standards, TOC measures, and population they would use in their review. ACMA provided three educational webinars, the opportunity for networking, and the blinded, comparative results of their organizational self-assessment.
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In the third month of the Learning Collaborative, the COVID-19 pandemic emerged and impacted both processes and outcomes of all participating organizations. For some organizations, results of their TOC assessment had identified opportunities around care transitions, which were then further emphasized during the surge of high-risk patients due to the pandemic. For other organizations, the results of the TOC assessment had motivated them to focus on communication processes prior to the pandemic. The TOC organizational assessment demonstrated its value by confirming performance or identifying transition of care opportunities. A TOC Learning Collaborative White paper is available at transitionsofcare.org/resources/learning-collaborative/. Why was the Tool Kit developed? The TOC pilot studies and Learning Collaborative offered ACMA many lessons regarding the best use and implementation of the TOC Standards and measures. The goal of the Tool Kit is to offer education and guidance to assess, measure, and improve care transitions across a continuum. The content of the Tool Kit includes best practices, references, and resources to guide case management leaders in their journey to improve care transitions.
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Who is this Tool Kit for? The TOC Standards are applicable to any care setting and this Tool Kit is intended for any health care entity working to improve care transitions. Some care models that may find this information useful include: • • • • • • • • • •
Acute Care Hospitals Community health agencies Integrated health systems Accountable Care Organizations Skilled nursing facilities/long term care Critical access hospitals Patient-centered medical homes Home Health agencies Payers Behavioral health
Next steps: 1. 2. 3. 4. 5. 6.
Review the following Case Study Review the Transition of Care (TOC) Standards on the ACMAweb.org website Review any current organizational TOC measures/outcomes utilized in your organization. Review references and resources (Learning Map, TOC Brainstorming Exercises) Review the TOC implementation tactics Download the TOC self-assessment tool from the TOC website transitionsofcare.org/standards/
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TOC Tool Kit Case Study Christine is an interim director at a 200-bed community hospital, which is part of a large system. She was brought in on a 6-month contract to assess the case management department’s strengths and opportunities around care transitions. As a member of the American Case Management Association, Christine had previous experience as a leader in several organizations. Christine recalled hearing about the Transition of Care Standards from the last ACMA conference. She thought the standards might help provide a method for assessing the status of care transitions at this hospital. Christine reviewed the Transitions of Care website (https://transitionsofcare.org), the five standards, and associated metrics. She found information regarding pilot case studies, a Learning Collaborative White Paper, and an implementation Tool Kit. Christine recognized that she could use these resources to assess the department’s current state. She downloaded the TOC assessment tool from the website. After reviewing the information, she called a meeting with her peers in the ACO and home health to discuss the self-assessment tool. Each of these care management leaders reported up through separate divisions. The consensus was for each leader to complete the TOC assessment for their respective areas and then compare results. Each leader reviewed the TOC metrics on the website and identified the metrics they were accountable for managing. After a group review, they recognized a wide variation in metric collection, as well as duplication of similar metrics. The post-acute leader had a dashboard to track metrics, but they were all receiving data from various sources and the reports were inconsistent.
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After the TOC assessment had been completed by all leaders, they met to compare their results. There were many competing priorities and at first, each leader preferred to focus on a different standard. After conferring with their respective leaders, a recommendation to form an organization-wide steering committee was made by the Chief Medical Officer. The CMO served as the executive sponsor and provided regular updates regarding the project across all divisions. After review, the committee agreed to focus on Standard 3, Perform and Communicate a Medication Reconciliation at each care transition, for each division. Key stakeholders from the pharmacy, physician leaders, quality & safety committee, performance improvement, and care coordinators from each division were included to discuss the results of the assessment. The committee reviewed the initiatives outlined in Standard 3, as well as the Phase II tactics outlined in the TOC Tool Kit. The scope of their focus would be three initiatives under Standard 3. The committee understood that medication reconciliation and communication are extremely important to patient safety, especially during transitions across care settings. Phase III tactics were reviewed and a commitment to review quarterly progress, develop standard dashboards to monitor progress, and share best practices was begun. What started as a departmental assessment opportunity grew to become an organizational commitment to improving medication reconciliation and communication across their system of care.
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Phase I: TOC Self - Assessment Tactics Formation of TOC Case Management steering committee Review focus priority areas
Download/print selfassessment tool from TOC website Identify/assemble entity subject matter expert (SME) to complete assessment Identify existing value-based care programs that currently exist within your organization
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Phase II: Action Guide for TOC Assessment Opportunity Tactics Compare assessment scores by each TOC standard
Acute care Entities within organization (Home Health, SNF, ACO, Rehab, Ambulatory CM, etc.) System
o o o
Hospital Entity System
o o o
Hospital Entity System
o o o
Hospital Entity System
Identify TOC standard(s)with the greatest opportunity
Prioritize areas for improving care transitions
Select TOC Measure(s) to monitor improvement
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Tactics Identify practices that must change o o o
Hospital Entity System
o o o
Hospital Entity System
Identify strategies to implement the change
For each strategy, identify who will be accountable for the implementation and outcomes
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Phase III: Implementation Tactics Communicate the plan; consider all key stakeholders
Implement the plan
Measure, review progress quarterly
Develop a dashboard of metrics
Monitor progress, revise as needed
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Phase IV: Post Implementation Follow-Up Tactics Complete a TOC postassessment at 6 month or yearly interval
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Resources Care Continuum Guidelines for Learning Map Exercise ACMA Learning Map-Blank Learning Map-Example Guidelines for the TOC Brainstorming Exercise TOC Brainstorming Exercise-Blank TOC Brainstorming Exercise-Sample Community/Continuum Partnerships 1. Cutts TF, Cochrane JR. Community asset mapping: integrating and engaging community and health systems. In: Cutts TF, Cochrane JR, eds. Stakeholder Health: Insights from New Systems of Health. Stakeholder Health; 2016:72-85. 2. Daniels M. Improving throughput by creating a community partnership with post-acute providers. Collaborative Case Management. 2019;May(69):7-13.
Leadership 1. Cross L, Mirken J, Moss J. Key case management skills for future leaders. Collaborative Case Management. 2019; January(69):19-22. 2. O’Boyle P. Case management leadership: recruitment and retention. Collaborative Case Management. 2019; July(78):17-20. ©2021 American Case Management Association www.acmaweb.org 12
Professional Standards of Practice ACMA standards of practice http://www.acmaweb.org/standards Acute inpatient rehabilitation, standards of practice https://rehabnurse.org/about/roles-of-the-rehab-nurse Ambulatory standards of practice https://www.aaacn.org/publications-news/scope-and-standards Behavioral health care coordination practice standards https://www.nursingworld.org/nurses-books/psychiatricmental-health-nursing-scope-and-standards-of-practice-2ndedi/ Home health & hospice standards of practice https://www.nahc.org/resources-services/regulatory-operational-resources/clinical-resources/ Transitions of Care 1. https://transitionsofcare.org/implementation/metric-alignment/ 2. McElroy D, Ferket K. The journey to metric alignment: transitions of care standards consensus measures. Collaborative Case Management. 2019;March(68):4-7.
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Value Based Care 1. AONE Guiding Principles for Value Based Care Delivery, AONE 2019. 2. Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, health and cost. Health Affairs. 2008;27(3):750-769. 3. Kindig D, Stoddart G. What is population health? AJPH. 2003;March;93(3):380-383. 4. Porter M. What is value in health care? New England Journal of Medicine. 2010;363(26):2477-2481. 5. Rasso R. Value based purchasing: are you part of the shift. Nursing Management. 2015;May:24-31.
Learning Collaborative Webinars •
Transitions of Care Learning Collaborative January 28, 2020 Webinar Recording
Navigating Post-Acute Challenges February 25, 2020 Webinar Recording
Workforce Challenges Across the Care Continuum March 24, 2020 Webinar Recording
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