Evidence-Based Care Across. White Paper. Authors: Grant G. Campbell MSN, RN Michele Norton MS, RN Clyde Wesp, Jr., MD, MA

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1 Evidence-Based Care Across the Continuum: Its Time Is (Finally) Now White Paper Authors: Grant G. Campbell MSN, RN Michele Norton MS, RN Clyde Wesp, Jr., MD, MA

2 Executive Summary Healthcare industry leaders are likely to relate to Einstein s observation. Achieving optimal patient outcomes by planning and coordinating clinical care across the entire continuum always has been a challenge. Nothing new about it. A confluence of industry forces, however, is creating an increased sense of urgency for reaching this long-standing goal. Understanding why there is a need for change is easy; it s the how that s difficult. Indeed, the real challenge for healthcare leaders rests in navigating the myriad challenges associated with the move toward the delivery of standardized evidence-based healthcare across the continuum of care. The results, however, are apt to be well worth the effort as the utilization of best practices across the continuum is expected to exponentially result in better patient outcomes, improved processes, and reduced costs. The release of atomic energy has not created a new problem. It has merely made more urgent the necessity of solving an existing one. - Albert Einstein A LONG HELD CARE CONCERN Continuity of care refers to the degree that care is coherent and linked. The value associated with coordinating care across the continuum has been recognized for quite some time. In fact, a British Medical Journal literature review that examined publications dated from 1996 to 2001 identified 2,439 unique documents related to the subject. 1 After analyzing these documents, researchers defined achievement of continuity of care as bridging discrete elements in the care pathway whether different episodes, interventions by different providers, or changes in illness status as well as by supporting aspects that endure intrinsically over time, such as patients values, sustained relationships, and care plans. In addition, the researchers found that for continuity to exist, care must be experienced as connected and coherent. The researchers also identified 3 different types of continuity: Informational continuity. The use of information on past events and personal circumstances to make current care appropriate for each individual. Management continuity. A consistent and coherent approach to the management of a health condition that is responsive to a patient s changing needs. Relational continuity. An ongoing therapeutic relationship between a patient and 1 providers. 1 A variety of studies suggest that continuity of care does, in fact, deliver value. For example, a study published in the Journal of the Royal Society of Medicine suggests that continuity results in benefits such as improved: Preventive care Quality of diabetes care Adherence to treatment Patient and physician satisfaction 2 Other studies illustrate the power of continuity as well. For example, research presented in the Archives of Family Medicine showed that higher provider continuity was associated with lower emergency department (ED) use among patients supported by Medicaid. 3 Similarly, a study in Pediatrics found that increased continuity of care was associated with a decreased number of visits to the ED and admissions to the hospital. 4 Evidence-Based Care Across the Continuum 2

3 The importance of carrying this continuity across providers also is coming into play. The National Quality Forum (NQF) has stated that care coordination helps ensure a patient s needs and preferences for care are understood, and that those needs and preferences are shared between providers, patients, and families as a patient moves from one healthcare setting to another. Care coordination is considered especially important for people with chronic or complex conditions who receive care in multiple settings from numerous providers. The NQF also has stated that care coordination maximizes the value of services delivered to patients by facilitating beneficial, efficient, safe, and highquality patient experiences and improved healthcare outcomes. 5 THE NEED FOR SPEED Although the concept of coordinated care across the continuum has been around for quite some time, the constant call to improve care quality has healthcare organizations feeling increased pressure to make such coordination a reality not just a nice-to-have. An examination of emerging trends sheds light on exactly what s behind this ever-more pervasive push to deliver evidence-based health care across the continuum. Increased consumer involvement in healthcare decision-making. Although patients were once content to accept what their healthcare practitioners offered as the unquestionable gold standard, they no longer do so. Today s patients are much more informed and are likely to question what healthcare professionals are providing and demand the best care possible. Of course, patients are garnering much of their knowledge from the Internet. According to a recent study, about 80% of Internet users have searched online for healthcare information.6 Patients don t just acquire the knowledge in a vacuum. Instead, they are interested in applying it to their own situation and, therefore, they have become more focused on staying on top of their health status as well. To support this consumer involvement, US Department of Health & Human Services Secretary Kathleen Sebelius recently proposed new rules that would expand the rights of patients to access their health information, specifically laboratory results, through the use of health information technology. When it comes to healthcare, information is power. When patients have their lab results, they are more likely to ask the right questions, make better decisions, and receive better care, said Secretary Sebelius. 7 Health reform and value-based purchasing. Under the Patient Protection and Affordable Care Act, health providers are no longer reimbursed solely on the quantity of services provided but instead on the quality of services. The Act s value-based purchasing program zeros in on how closely hospitals follow best clinical practices and how well hospitals enhance patients care experiences. Beginning in 2013, hospitals will incur a payment reduction if they have readmissions within 30 days of discharge for patients with myocardial infarctions, heart failure, and pneumonia. By 2015, most hospitals will face reductions in Medicare payments if they do not meaningfully use information technology to deliver better, safer, more coordinated care. As such, health care organizations can no longer focus only on the static inpatient care experience but also must focus on the entire spectrum of services across the continuum that ultimately contribute to patient outcomes. Partnership for Patients program. Introduced in 2011, this federally funded program focuses on preventing injuries and complications in hospital patients. While the program aims to address all forms of harm to patients, it is initially focusing on 9 types of medical errors and complications where the potential for dramatic reductions in harm rates has been demonstrated by pioneering hospitals and systems across the country. Examples include preventing adverse drug reactions, pressure ulcers, childbirth complications, and surgical site infections. Overall, the program aims to save 60,000 lives over 3 years by avoiding millions of preventable injuries and complications in patient care. In addition, the Partnership for Patients initiative also has the potential to save up to $35 billion in healthcare costs over 3 years, including up to $10 billion in Medicare expenditures alone. Evidence-Based Care Across the Continuum 3

4 Emerging Meaningful Use requirements. Meaningful Use Stage 2 requirements focus more closely on advancing clinical processes. For example, the Stage 2 requirements include a more robust transitions of care measure that actually requires the electronic exchange of summary of care records, not merely the exchange of key clinical information. More ambitious patient engagement requirements are also included. For instance, CMS replaced the provide patients with an electronic copy of their health information Stage 1 objective with a provide patients with the ability to view online, download, and transmit their health information Stage 2 core objective. Meaningful Use Stage 3 requirements are expected to zero in on outcomes by requiring providers to improve quality, safety, and efficiency that will lead to improved health outcomes; adopt decision support for national high-priority conditions; provide patients with access to self-management tools; enable access to comprehensive patient data through patient-centered health information exchanges; and support population health improvements. The rise of accountable care organizations. From its inception, the reform legislation generated significant interest in accountable care organizations (ACOs). An ACO is a group of providers that is willing to work together to manage and coordinate the care of the group s assigned Medicare fee-for-services beneficiaries and to be accountable for the quality, cost, and overall care of these beneficiaries. If the group through the management and coordination of these Medicare beneficiaries care is able to provide high-quality, accessible care at a significant savings to Medicare, then the providers in the group share this savings. The ultimate goal is not to pay providers on the basis of the number of tests they order and procedures they perform, but rather on the basis of their provision of high-quality, accessible, coordinated, low-cost care. Various permutations of the ACO concept are already emerging separately from Medicare, incorporating a variety of models for provider cost and quality incentives as well as patient care coordination by a wide range of providers. While the ACOs are likely to take on a variety of forms, the goal is to create the relational continuity that will help providers and patients interact more consistently and effectively. ALL TYPES OF CARE With these trends providing the motivation, healthcare organizations are seeking to coordinate care across the continuum and, therefore, improve outcomes in a variety of situations. For example, improvements in informational continuity can help enhance preventive care efforts. Currently, in most cases, there is no system in place to monitor if a patient is receiving the appropriate preventive care across providers. Because providers do not share patient information, it s difficult to determine if patients get the appropriate services whether it immunizations, dental exams, or colonoscopies at the appropriate ages. Management continuity can also lead to improved preventive care. Clinical decision support (CDS), for instance, can help prompt individual providers to offer needed services. At the same time, health information exchanges could provide a source of truth, enabling individual care providers to ensure that patients are receiving all recommended preventive services. If care is coordinated across the continuum, preventive services could be offered and tracked as the consumer moves from care venue to care venue or from provider to provider ie, as a child moves from pediatrician to college health center to internist. Continuity of care also can help improve outcomes in acute care situations. For example, a study in the Journal of Nursing Care Quality illustrates how a coordinated initiative for patients with heart failure was planned and implemented across an entire healthcare system to: (1) incorporate best evidence-based practice to rapidly stabilize the patients, and (2) establish early, coordinated patient education to promote self-care at home with the support of appropriate resources. Because of this coordinated effort, management continuity was improved and length of stay and readmissions were significantly reduced. 8 Evidence-Based Care Across the Continuum 4

5 Indeed, information technology can be leveraged to greatly improve care transitions. For example, by sharing information electronically, SBAR (situation background assessment recommendation) reporting can be streamlined. Under this scenario, information can be quickly relayed or transmitted to rapid response teams, expediting the treatment of conditions such as sepsis, which could prove fatal if not treated immediately. Creating continuity of care across disciplines also can help improve chronic conditions. For example, a patient with rheumatoid arthritis might receive services from several providers, including an internist, rheumatologist, acupuncturist, physical therapist, wound specialist, and podiatrist. If all of these providers are providing care as prescribed by a coordinated care plan and providing evidencebased best practice at each juncture management continuity and subsequently the quality of care is likely to improve. In addition, if each provider has access to the patient s complete medical history, informational continuity will improve and the providers will then have a better understanding of what types of treatments work and what types do not. For example, a wide spectrum of drugs is used to treat rheumatoid arthritis, but patients respond to these drugs very differently. By sharing information about the individual patient, the caregivers are likely to more expediently zero in on effective and complementary treatments. As such, costs are likely to decrease as the various providers would be less likely to provide duplicative services. FROM VISION TO REALITY Acknowledging the benefits of care coordination across the continuum is only the first step. Healthcare organizations also need to implement a variety of strategies to bring the vision to fruition: Embracing a culture of safety and accountability. Healthcare leaders need to make continuity of care across the continuum a vital component of the organization s culture. As such, leaders need to make care coordination among providers an absolute imperative, not an occasional choice. The New Jersey Hospital Association Pressure Ulcer Collaborative, which includes about 150 healthcare organizations, provides an example of what can be accomplished simply by committing to and supporting change. The effort resulted in a 70% reduction in the incidence of new pressure ulcers. The improvement did not emanate from a revolutionary treatment but instead from utilizing a commonly known best practice skin assessment and, perhaps more importantly, supporting the intervention by getting all stakeholders involved, developing a customized patient-centered process, and having the right tools for the staff to use at the point of care. 9 Creating a plan. For each patient, healthcare organizations should create and sustain a longitudinal care plan, which will direct how care is delivered across the continuum. Such a document can be thought of as a single aligned plan of care, semantically available to all disciplines involved, containing information from disparate health and non-health sources, and fully available to the care/service recipient and capable of guiding care and interacting with health IT systems to maintain alignment. 10 Under the government s Meaningful Use Stage 2 requirements, providers will be required to share such care plans. At a minimum, these plans should contain basic data about the patient, summaries of the patient s episodes of care and updated status of current problems. As such, when a patient presents at a new organization, the caregiver will already have a basic understanding of the patient s health and his or her response to various interventions. The care plan could drill down so far as to offer insight into the type of communication that a patient is more likely to respond to. For example, a plan might note that a teen patient is more likely to comply with care instructions delivered via text messages than those delivered in person. Evidence-Based Care Across the Continuum 5

6 Designing and implementing a technology infrastructure that supports communication and data exchange. Healthcare organizations should provide a vehicle that will transfer information from one provider to the next in an efficient, safe, and secure manner. For example, if a child is showing early signs of diabetes, it would be necessary to share historical information regarding the child and his parents among the primary care physician, obstetrician, pediatrician, and endocrinologist. To do so, all of these providers need to work from an integrated electronic system that shares information seamlessly. Organizations are exploring a variety of ways to improve the sharing and exchanging of patient information, including innovative technologies to connect disparate electronic health record (EHR) systems. For example, cloud technology could help organizations safely and securely share information. In addition, organizations are relying on existing methods such as the phone and fax, or simply providing the information to a patient to share with other providers, while waiting for more advanced technologies to be adopted in their facilities. To effectively exchange information, organizations need to agree on the critical information to be shared and how they share the information. Forging collaboration. To move forward, healthcare organizations need to create an environment where clinicians have the capacity and willingness to invest the time and energy in specific care coordination efforts. Organizational leaders, therefore, need to demonstrate a real commitment to safety by investing in leadership to manage these initiatives. In addition, the organization needs to set standards and establish accountability. With such expectations in place, organizations will need to define new roles and responsibilities for caregivers and other staff members, all designed to improve care collaboration. Realizing community engagement. To truly experience the best outcomes, the continuum of care should be thought of in broad terms and should include the family, community, schools, and other community organizations. As such, the healthcare industry can move away from the concept of healthcare being delivered by a clinician during an episode of treatment to wellness being maintained through a variety of educational, preventive, and treatment interventions. Building consensus around standardized evidence-based best practices. Coordinating care across the continuum also means that organizational leadership and clinicians are committed to the adoption of standardized evidence-based best practices. Lack of care standardization often results in care variability, confusion for patients and families, and difficulty in realizing improved outcomes. Some healthcare organizations have employed these strategies to successfully share information and coordinate care across the continuum. At Riverside Regional Medical Center, for example, leaders implemented a Patient-Centered Care Coordination project (PC3@RHS), designed to streamline the development of evidence-based protocols that span the care continuum. Previously, individual providers working in silos struggled with the development of CDS capable of standardizing care across the continuum. Under PC3@RHS, clinicians formed an enterprise-wide team that works with a unified governance process to leverage evidence-based CDS and then efficiently deploy these standardized best practices to the individual providers. By working collaboratively, Riverside has reduced the time and resources required to maintain a CDS initiative. Similarly, at Kettering Health Network, interdisciplinary specialty groups that included a team leader and primarily bedside staff led the development of an enterprise EHR with standardized CDS. The teams customized about 160 care plan templates from an outside resource in an effort to meet the expectations of clinicians. After a 4-month, 3-phased implementation, these teams declared success as the health system is now offering standardized, evidence-based care plans and easy-to-use computerized physician order entry to its physicians across the enterprise. Evidence-Based Care Across the Continuum 6

7 Other healthcare organizations are embracing similar initiatives, as the industry is experiencing the perfect storm of forces that will move the utilization of standardized evidence-based best practices from a concept to a reality. For starters, the government is not only calling for increased care coordination but is starting to financially reward such coordination through the Meaningful Use initiative as well as the move toward value-based purchasing under health reform. In addition, as consumers seek to stay well and improve their own healthcare outcomes, they will also demand higher levels of care coordination. The fact that emerging technologies can enable data sharing and the utilization of CDS at the point of care will accelerate the adoption of enterprise-wide best practices across the continuum of care. While organizations will need to overcome a variety of challenges to support the delivery of standardized best practices across the entire patient care experience, the fact that the effort is expected to exponentially improve clinical care and financial outcomes will motivate organizations to move forward by creating the culture, adopting the technology, and supporting the initiatives that will make evidence-based best practices across the continuum a reality. Indeed, with all of these forces in play, organizations essentially will have the atomic energy required to successfully overcome the myriad challenges associated with coordinating care across the continuum. References 1. Haggerty JL, Reid R, Freeman GH, Starfield BH, Adair C, McKendry R. Continuity of care: a multidisciplinary review. BMJ. 2003;327(725): Gray, DP, Evan P, Sweeney K, Lings P, Seamark C, Dixon M. Towards a theory of continuity of care. J R Soc Med. 2003;96(4): Gill JM, Mainous AG III, Nsereko M. The effect of continuity of care on emergency department use. Arch Fam Med. 2000;9: Christakis DA, Mell L, Koepsell TD, et al. Association of lower continuity of care with greater risk of emergency department use and hospitalization in children. Pediatrics. 2001;107: National Quality Forum, NQF-Endorsed Definition and Framework for Measuring Care Coordination, May 2006, Endorsed aspx?section=publicand MemberComment #t=1&s=&p. Accessed March 13, Pew Internet Project. Health Topics. PIP_Health_Topics.pdf. Accessed March 13, Health and Human Services. Press Release: Secretary Sebelius spotlights new efforts to empower patients to increase secure access to health information. September 12, Accessed March 13, Miranda M, Gorski L, et al. An evidence-based approach to improving care of patients with heart failure across the continuum. Journal of Nursing Care Quality. 2002;17(1): McKnight s Long-Term Care News. State collaborative boasts 70% reduction in pressure ulcers. July 18, Accessed March 13, Standards & Interoperability Framework. Longitudinal Care Plan SWG Charter. Accessed March 13, Evidence-Based Care Across the Continuum 7

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