Date:
May 8th, 2014
From: Nate Hunkins
Manager, Business & Systems Dev.
MN Community Measurement
Re:
Collette Pitzen, RN BSN CPHQ
Clinical Measure Developer
MN Community Measurement
Health Care Homes Care Coordination Measures- Pilot Results
Purpose of Measures:
The measures, following successful pilots, are intended for quality improvement purposes and for use in
evaluation and recertification of Health Care Homes in MN. No current plan for public reporting.
1. Advance Care Planning Ages 65 and older
2. Follow-up After Hospital Discharge; selected clinical conditions
Enclosures/Attachments:
 Summary Advance Care Planning Measure & Recommendations (page 3)
 Advance Care Planning Complete Pilot Report (page 5)
 Advance Care Planning Measure and Field Specifications (separate attachment)
 Summary Follow-up After Hospital Discharge Measures & Recommendations (page 22)
 Follow-up After Hospital Discharge Measure Pilot Report (page 24)
 Follow-up After Hospital Discharge Measure and Field Specifications (separate attachment)
Greetings,
The Health Care Home Care Coordination Measure Development Work Group is pleased to present the
pilot results and their recommendations for two measures related to care coordination.
The measure development process for the measure concept of “care coordination” was launched based
on a contractual agreement between MNCM and the Minnesota Department of Health- Health Care
Home Division in September 2011. MNCM’s Measurement and Reporting Committee (MARC) and the
HCH Performance Measurement Committee reviewed the measure specifications in early 2013 and
approved two measures for pilot testing. We are pleased to report successful pilot testing of these
measures.
Robust work group discussion occurred during its reconvening to review pilot results and some redesign
was recommended to reduce burden.
We look forward to presenting these measures, results and recommendations to you in more detail.
Additionally, we would like to thank the measure development work group for their participation and
commitment over the last two and a half years.
Health Care Homes Care Coordination Measure Development Work Group:
Name
Member Type
Organization
Amy Burt, DO
Pediatrician
Park Nicollet
Demeka Campbell, MD
Hospitalist
HealthPartners
Name
Member Type
Organization
Pat Fontaine, MD
Family Medicine
HealthPartners Research
Jeff Schiff, MD
Pediatrician; State Agency
MN Department of Human Services
Beverly Reiman
Nursing
Allina Medical Group
Cindy Walsh
Nursing
Westside Community Health
Karen Peterson
Nursing
Sanford Health
Leanne Roggemann
Nursing
Fairview Health System
Linda Zarns
Nursing
Fairview Health System
Ronda Nading
Nursing
Mayo Clinic
Patti Rickheim
Nursing
Park Nicollet
Linda Ferry
Nursing
Park Nicollet
Catherine Vanderboom
Nursing
Mayo Clinic
Mary Larson
Nursing
Mayo Clinic
Stephanie Witwer
Nursing
Mayo Clinic
Kim O'Brien
Data Analyst
Hennepin County Med Center
Lisa Aker
Data Analyst
HealthPartners
Cindy Severson
QI
Mayo Clinic
Kate Nienaber
QI
CentraCare
Terry Murray
QI/ Data Analyst
Allina Medical Group
Amy Johnson
Health Plan
Medica
Marie Maes-Voreis
State Agency
MDH/ Health Care Homes
Carolyn Allshouse
Consumer
FamilyVoices MN
Lisa Regehr
Other
MN Academy Family Physicians
Virginia Barzan
Other
MN Academy Family Physicians
Kathy Cummings
Other
Institute Clinical Systems Improvement
Nate Hunkins
Facilitator
MNCM
Collette Pitzen
Measure Dev
MNCM
Health Care Homes Care Coordination Pilot Summary
Advance Care Plan
High level summary; please refer to full pilot report for more details
Numerator:
Evidence (documentation) of advance care planning (ACP) in the medical record at their health
care home clinic
Denominator: Patients ages 65 and older
Exclusions:
Pilot:






None
8 Medical Groups; 68 Clinics and 56,764 patients
Average rate of ACP was 32.1%
Ranges by Medical Group (top graph) and by clinic
(bottom graph) demonstrate opportunity and variability
Pilot tested presence of 2 components within the ACP
o The patient’s wishes are outlined
o The patient’s decision-maker is defined
During pilot, component of decision-maker proved problematic.
Biggest concern was the POLST (Physician Order’s for Life sustaining
Treatment) an AMA sponsored tool that does a great job of outlining
patient’s wishes, but does not have a place to designate decision
maker.
Although extremely important to designate a decision maker, the
work group decided to focus measurement efforts on the
documentation of patient wishes as the key component of any
advance care plan documentation that is used.
Recommendation:
The measure development work group recommends that this measure be
considered for use in quality improvement and may be used for the purposes
of health care home clinic evaluation and certification processes.
Modifications: (made to specifications as a result of pilot)
After careful consideration of the intent of the measure, to encourage
conversations about end-of-life issues with patients and to have the patient’s
wishes communicated, the work group recommends the following
modifications:


Remove component designated decision maker
Allow a DNR/DNI (do not resuscitate/ do not intubate) order to be included as numerator compliant;
indicates that discussion did occur with patient and/or family about the patient’s wishes.
Specifications will be enhanced to include examples of the types of forms or documentation that can be used
to meet the intent of ACP and additional guidance/ resources will be provided to groups in terms of best
practice for advance care plan discussions and documentation.
Provide additional considerations (in the specs) indicating that the work group stills feels that a designated
decision maker is important, is a part of best practice, but that it will not be measured/ included in the
numerator at this time.
Health Care Homes Care Coordination Pilot Summary
Advance Care Plan
For Information Only: Additional Guidance for Acceptable Documentation of Advance Care Planning
The purpose and intent of this measure is to increase the rates of patients age 65 and older who have
documentation of advanced care planning in their medical record in an effort to improve the coordination of
care and promote end-of-life discussions. The measure development group did not want to be prescriptive in
terms of the type, format or content of this documentation; rather wanted to focus on evidence that the
patient’s wishes are documented. Additionally, the work group did not want to add undue data collection and
submission burden by requiring groups to submit detail about the patient’s wishes. Groups indicate if the
patient does indeed have an ACP present in the medical record (yes/no) and then during the validation audit
for a sample of records, the content of the patient’s ACP will be reviewed and validated for content that
includes patient wishes.
Please note that while most medical groups use a type of form to hold this documentation; the use of a form is
not required for numerator compliance. Any documentation of patient wishes is acceptable and can include
the patient identifying a surrogate decision maker. In addition to forms (scanned or part of a paper chart),
groups can use care plans, discrete EMR fields indicating the presence of an ACP, discrete EMR fields that
indicate patient wishes or progress notes as evidence of documentation of an advance care plan present in the
record. The following methods/ types of documentation are acceptable:




Scanned document in an EMR
Paper document in a paper chart
Care plan that includes patient wishes
Order for DNR/DNI (Do Not Resuscitate/ Do Not Intubate)
The following are an examples of forms or types of forms that can be used to meet the intent of an ACP;
however the list is only a suggestion and not all-inclusive.







Honoring Choices
Five Wishes
POLST Physician Orders for Life Sustaining Treatment
MN Advanced Directive/ Caring Connections
Advance Directive
Living Will
Durable Power of Attorney
Resources for Advance Directives/ Advance Care Planning and Best Practices:
Organization
Link for More Information
Honoring Choices
www.honoringchoices.org/resources/
www.metrodoctors.com/dev/index.php/healthcare-directives
Five Wishes
www.agingwithdignity.org/forms/5wishes.pdf
POLST
www.mnmed.org/Portals/mma/PDFs/POLSTform.pdf
MN Advance Directive/ Caring Connections
www.caringinfo.org/files/public/ad/Minnesota.pdf
National Cancer Institute
www.cancer.gov/cancertopics/factsheet/Support/advance-directives
American Cancer Society
www.cancer.org/treatment/findingandpayingfortreatment/
understandingfinancialandlegalmatters/advancedirectives/advance-directives-toc
NIH National Institute on Aging
www.nia.nih.gov/health/publication/advance-care-planning
Centers for Disease Control
http://www.cdc.gov/aging/pdf/acp-resources-public.pdf
MNCM Health Care Homes- Care Coordination Advance Care Plan
(ACP) Complete Pilot Analysis and Results – April/May 2014
Recommendation
After careful consideration of the intent of the measure, to encourage conversations about end-of-life
issues with patients and to have the patient’s wishes communicated, the work group recommends the
following modifications:
 Remove component designated decision maker
 Allow a DNR/DNI (do not resuscitate/ do not intubate) order to be included as numerator compliant;
indicates that discussion did occur with patient and/or family about the patient’s wishes.
Specifications will be enhanced to include examples of the types of forms or documentation that can be
used to meet the intent of ACP and additional guidance/ resources will be provided to groups in terms
of best practice for advance care plan discussions and documentation.
Provide additional considerations (in the specs) indicating that the work group stills feels that a
designated decision maker is important, is a part of best practice, but that it will not be measured/
included in the numerator at this time.
The measure development work group recommends that this measure be considered for use in quality
improvement and may be used for the purposes of health care home clinic evaluation and certification
processes.
Background
As part of a contractual relationship with the MN Department of Health (MDH) and the Health Care
Homes Division, MNCM was selected as a sub-contractor for the development of new measures for the
measure concept of care coordination. Measure development activities around this concept are
intended for the purposes of quality improvement and program evaluation and at this time there are no
current plans for use in public reporting. Following successful pilot completion and implementation for
health care homes clinics, there may be interest for inclusion in other programs.
The Measurement and Reporting Committee (MARC) and the HCH Performance Measurement
Workgroup reviewed the impact of potential measures for care coordination and approved measure
development activities for this topic. Of note, there is national interest in developing more outcome
measures, however it is recognized that the measure concept of care coordination lends itself to
measures that reflect the processes of care provided (medication reconciliation, follow-up after referral
to a specialist, contents of a hospital discharge summary or continuity of care record, etc.) One of the
challenges for the work group was to narrow the potential topics of interest for care coordination and to
design meaningful, feasible measures. Areas of care coordination were explored and ranked by work
group members as having the most impact on patient outcomes. In order of importance:
communication and education, care transitions, patient experience, medication reconciliation, provider
to provider communication, access to care, care plans and community collaboration. A sub-group met to
explore potential process measures that would reflect coordination of care and ultimately the work
group decided on two individual measures; one for adults age 65 and older reflecting documentation in
the record of an advance care plan and the second for adults with select conditions who are contacted
within a certain number of days for follow-up after hospital discharge.
© MN Community Measurement, 2014. All rights reserved.
March 2014
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MNCM Health Care Homes- Care Coordination Advance Care Plan
(ACP) Complete Pilot Analysis and Results – April/May 2014
Developmen
t Time Line
Task
Date/s
Research/ environmental scan for care coordination
August 2011
Impact presented at MARC, development approved
September 2011
Work group member recruitment
October/ November 2011
st
1 measure development meeting
nd
1/27/2012
rd
2 and 3 measure development meetings
3/1/2012, 3/27/2012
Sub- group for measure selection (meeting # 4)
5/11/2012
Meetings # 5, 6, and 7
July- October 2012
Measure specifications completed
November 2012
Public Comment
11/16 to 11/30/2012
Work group reconvene for redesign after public comment
1/10/2013
MARC approval for pilot of 2 measures
2/13/2013
Pilot dates of service (three months)- Advance Care Plan
7/1/2013 to 9/30/2013
Data Submission- Advance Care Plan
10/15 to 11/8/2013
Validation audits- Advance Care Plan
Nov/ December 2013
Survey Pilot Tools, Data and Burden
January 2014
Pilot analysis and re-convene
February 2014
Pilot Goals/ Objectives- Advance Care Plan
 Pilot to allow groups time to prepare for implementation dates of service starting 7/1/2013
 Feasibility of capturing data to demonstrate that advanced care planning did indeed occur without
adding undue data collection burden. Development work group did not want to dictate the
contents nor require that a formal advance directive document be used; rather wanted to insure
that two key aspects were contained as part of the documentation: patient’s wishes and a
designated decision maker.
 Rather than adding burden of collecting data elements that indicate the two key aspects were
present; work group decided that a simple Yes/ No binary field would suffice and that validation
audit would demonstrate what a sample of records at each participating pilot site actually do
indicate in terms of content related to patient’s wishes and designated decision maker.
 Evaluate strength of proposed measures- rates demonstrate variability and results meet original
intent of the measures to 1) promote and support the discussion of end of life issues and 2)
coordinating care and provide access to information.
 Identify missing elements or components of measures.
 Record and track lessons learned. Share questions/ answers/ successes/ challenges via “list serv”
 Improve measure by incorporating feedback and providing clarification to improve data collection
guide and instructions.
 Facilitate work group discussion to address common challenges in collecting and reporting data.
Pilot Results- HCH Care Coordination Advance Care Plan
Eight medical groups participated in the pilot submission for the Advance Care Plan Measure
representing 68 clinic site locations.
© MN Community Measurement, 2014. All rights reserved.
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MNCM Health Care Homes- Care Coordination Advance Care Plan
(ACP) Complete Pilot Analysis and Results – April/May 2014
Race/Ethnicity
99.6% capture; 0.4% blank
Demographics of Pilot Patients
N = 56,764 patients
40.6% male, 59.4% female
95.8%
1.2%
1.0%
1.0%
0.5%
0.3%
0.2%
<0.1%
<0.1%
<0.1%
Metric
Results
Number of Patients Submitted
56,764
Documentation of Gender
100%
Advance Care Plan in Patient’s Medical
Record
Notes/ Thoughts
Opportunity for improvement
Yes
No
32.1% (18,212)
67.9% (38,552)
Reason for No Advance Care Plan
Patient Declined
Discussion Never Occurred with Patient
Currently in Process
1.0% (384)
98.6% (38,003)
0.4% (165)
Race
White
Choose Not to Disclose
Asian
Black or African American
Multiracial
Hispanic or Latino
American Indian/ Alaska Nat
Native Hawaiian/Pacific Isl
Unknown Race
Some Other Race
Overall Total
White
Choose not to Disclose
Asian
Black/African American
Multiracial
Hispanic or Latino
Am. Indian or Alaskan Native
Native Hawaiian/Pacific Isl.
Unknown
Other Race
Advance Care Plan
17,757
104
83
93
69
40
21
7
2
10
18,212
Needs discussion.
Burdensome? Groups indicated
difficulty and may have filled
field with discussion never
occurred
Low % decline or in progress
Total Patients in Race
54,135
670
572
546
292
166
89
22
3
32
56,764
© MN Community Measurement, 2014. All rights reserved.
March 2014
Advance Care Plan Rate
32.8%
15.5%
14.5%
17.0%
23.6%
24.1%
24.6%
31.8%
66.7%
31.3%
32.1%
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MNCM Health Care Homes- Care Coordination Advance Care Plan
(ACP) Complete Pilot Analysis and Results – April/May 2014
Measure: Advance Care Planning
Percentage of patients age 65 or older at the start of the measurement year who have evidence
(documentation) of advance care planning (ACP) in their medical record at their health care home clinic.
Patient has a written advance care plan in the chart with the following documented:


The patient’s wishes are outlined
The patient’s decision-maker is defined
# of patients age 65 or older with evidence of advance care plan in their medical record
# of patients age 65 or older
Notes: Decision by the work group to not collect discrete data (individual fields) about the content of
the ACP; rather set the expectation that whatever documentation is used that it contains the
two key items (patient’s wishes outlined and decision-maker) and then use the validation
process to assess.
Existing HEDIS (NCQA/ NQF# 0326) measure includes a surrogate decision maker, but it is
considered an “OR”. Measure is used in the PQRS program, but is not in the meaningful use set.
Numerator is stated as: Patients who have an advance care plan or surrogate decision maker
documented in the medical record or documentation in the medical record that an advance care
plan was discussed but patient did not wish or was not able to name a surrogate decision maker
or provide an advance care plan. Denominator is all patients age 65 and older.
Need: Post-pilot discussion about what types of documentation do meet the intent of discussion
occurring and plan (documented) in place. Could have a more comprehensive list in terms of
what “counts” as documentation. Some ideas/ suggestions for discussion:
Suggested Documents/ Forms:








MN Advance Directive (Caring Connections, UofM)
Honoring Choices
Five Wishes
POLST Physician Orders for Life Sustaining Treatment
o (AMA, great form but no place for designating a decision-maker)
Advance Directive
Living Will
Durable Power of Attorney
Others?
Suggested Care Plan/ Progress Note Documentation:
 Any documentation of patient wishes
 Any documentation of a surrogate decision maker
 Do Not Resuscitate/ Do Not Intubate
 Do we want to include this? Does indicate that discussion did occur w/ patient or family
© MN Community Measurement, 2014. All rights reserved.
March 2014
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MNCM Health Care Homes- Care Coordination Advance Care Plan
(ACP) Complete Pilot Analysis and Results – April/May 2014
Advance Care Plan Rates by Medical Group (8 Medical Groups, 69 Clinics)
Medical Group
S
B
V
T
L
X
W
U
Overall Rate
Advance Care
Plan Rate
Patients
Submitted
97.4%
45.8%
39.2%
32.4%
2425
7145
120
185
31.1%
30.3%
24.3%
12.8%
32054
1394
3292
10149
32.1%
56764
© MN Community Measurement, 2014. All rights reserved.
Please See Appendix A for Blinded
Medical Group and Clinic Rates
Average Rate of Advance Care Plan.
Red line is at or above average.
March 2014
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MNCM Health Care Homes- Care Coordination Advance Care Plan
(ACP) Complete Pilot Analysis and Results – April/May 2014
Advance Care Plan Rates by Clinic
Please See Appendix A for Blinded
Medical Group and Clinic Rates
© MN Community Measurement, 2014. All rights reserved.
March 2014
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MNCM Health Care Homes- Care Coordination Advance Care Plan
(ACP) Complete Pilot Analysis and Results – April/May 2014
Resource Use and Data Burden
Survey fielded from January 10th to January 17th, 2014 to all pilot participants (n = 136)
Received 11 responses (8.0 % response rate) representing 5 medical groups and includes 6 quality
improvement staff, 2 clinic administrators, 2 other health professionals and 1 data analyst.
Survey respondents participating in the Advanced Care Measure: 7
Electronic Medical Record Capture
80% (4) – All data for submission extracted from EMR
20% (1) – Hybrid method (EMR and some manual abstraction)
0% (0) – Clinic has paper chart records; no EMR
Estimate of % Time Manually Abstracting Data
3
0%- all EMR
1 to 20%
21 to 40%
Estimate Hours to Program and Abstract Data
Less than 20
1
20 to 40
1
41 to 60
1
41 to 60%
61 to 80
61 to 80%
81 to 100
81 to 100%
101 or more
Estimate of Hours in Addition to Program
1 to 10
2
11 to 20
Staff for Collecting & Preparing Data
one
two
21 to 30
1
three
31 to 40
1
four
41 to 50
3
3
1
Five or more
1
1
51 +
Comments from medical groups about Advance Care Plan Measure:
 Our medical group has limitations in the way the Advanced Care Plan and DNI/DNR are filed in our
Epic system. These 2 documents are filled exactly the same resulting in the report not being able to
distinguish the difference.
Data Element
Advance Care Plan in Patient’s Medical Record
Very
Easy

Reason No Advance Care Plan
Easy
Difficult
Very
Difficult



Note each  represents one response from survey participant
© MN Community Measurement, 2014. All rights reserved.
March 2014
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MNCM Health Care Homes- Care Coordination Advance Care Plan
(ACP) Complete Pilot Analysis and Results – April/May 2014
Additional information from Survey (each  represents one response from survey participant)
Q 11- For those patients age 65 and older why do you think ACP’s are not being completed?



Have good work flow processes in place, but patients refuse
Mixed; processes in place but not consistent and unsure about refusal versus documentation
not returned
Other, have implemented Honoring Choices but before processes were put in place, info was
not in a consistent place in the record therefore hard to extract
Q 13- We have received feedback during the pilot that in some cases the patient does not chose to
designate a decision maker. Would you prefer to collect and submit additional data about the content of
the ACP, allowing for separation of the two components and different measure calculations?


No, do not support additional data collection
Yes, prefer additional data collection and ability to stratify by components
Q-14 Please indicate your ability to obtain discrete information about the patient's wishes and
designated decision maker.


No ability to electronically capture patient’s wishes
Yes, have ability to electronically capture patient’s wishes

No ability to capture designated decision maker
Q 15- What type of review did you complete for this measure?


Have a field to indicate ACP; did No manual review to verify contents
Have a field to indicate ACP; did SOME manual review to verify contents
All respondents had a field to capture the presence of an ACP and no one indicated that they did
extensive manual review.
Results from Validation Audit: [Please refer to Appendix B for full report]
 Some systems include DNR/DNI documents as an ACP in their documentation/ scanning process
storing in the same discrete field “Healthcare Directive/ Code Status”. Would require 100% manual
abstraction to determine if it is a health care directive versus DNR/DNI.
 It appears that many groups are utilizing formal documents like POLST, Honoring Choices, MN
Healthcare Directives, and Five Wishes as opposed to progress notes/ care plans.
 One medical group with a lower rate experienced a staff departure that could have influenced how
the data was extracted.
Conclusion:
The validation process was successful in identifying errors and verifying the accuracy of the data
submitted by the participating pilot medical groups. MNCM recommends that the pilot data for this
measure be used for rate calculation and further data analysis with the consideration of the two medical
groups that coded DNR as a “Healthcare Directive”.
© MN Community Measurement, 2014. All rights reserved.
March 2014
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MNCM Health Care Homes- Care Coordination Advance Care Plan
(ACP) Complete Pilot Analysis and Results – April/May 2014
Appendix A
Display of Advance Care Plan Rates by Medical Group and Clinic; Blinded
Medical
Group
Clinic
ID
B
B
163
164
47.0%
49.2%
B
003
43.3%
B
004
38.8%
B
005
45.1%
B
006
40.5%
B
007
46.8%
B
008
41.1%
B
010
44.8%
B - Medical Group Total
Advanc e Care
Plan R ate
45.8%
L
L
160
161
34.5%
35.0%
L
162
32.3%
L
039
20.3%
L
040
40.7%
L
041
34.1%
L
042
30.3%
L
043
35.7%
L
044
28.9%
L
045
29.8%
L
046
26.0%
L
047
23.3%
L
048
39.2%
L
049
26.8%
L
050
28.7%
L
051
27.5%
L
052
40.6%
L
053
28.2%
L
054
32.7%
L
055
35.6%
L
056
31.7%
L
057
23.8%
L
058
30.2%
L
059
24.4%
L
060
26.9%
© MN Community Measurement, 2014. All rights reserved.
March 2014
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MNCM Health Care Homes- Care Coordination Advance Care Plan
(ACP) Complete Pilot Analysis and Results – April/May 2014
Medical
Group
Clinic
ID
L
L
061
062
25.5%
25.1%
L
063
32.9%
L
064
20.7%
L
065
31.3%
L
066
20.7%
L
068
20.0%
L
069
36.6%
L
070
32.8%
L
071
29.9%
L - Medical Group Total
31.1%
S
176
S - Medical Group Total
T
174
T - Medical Group Total
Advanc e Care
Plan R ate
97.4%
97.4%
32.4%
32.4%
U
U
149
150
14.4%
13.2%
U
151
12.2%
U
152
10.5%
U
153
14.9%
U
154
6.3%
U
155
5.7%
U
156
8.6%
U
157
13.5%
U
158
16.5%
U
159
23.1%
U
165
14.3%
U - Medical Group Total
V
V
148
173
V - Medical Group Total
12.8%
35.0%
43.3%
39.2%
W
W
166
167
24.3%
21.5%
W
168
26.0%
W
169
22.1%
W
170
24.2%
W
171
28.1%
© MN Community Measurement, 2014. All rights reserved.
March 2014
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MNCM Health Care Homes- Care Coordination Advance Care Plan
(ACP) Complete Pilot Analysis and Results – April/May 2014
Medical
Group
Clinic
ID
W
172
W - Medical Group Total
X
175
Advanc e Care
Plan R ate
19.2%
24.3%
30.3%
X - Medical Group Total
30.3%
Overall Rate
32.1%
© MN Community Measurement, 2014. All rights reserved.
March 2014
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MNCM Health Care Homes- Care Coordination Advance Care Plan
(ACP) Complete Pilot Analysis and Results – April/May 2014
Appendix B
Validation Summary | Summary Report on the Validation Process for the HCH Care
Coordination Advance Care Plan| Pilot Dates of Service 7/01/2013 to 9/30/2013
Background and Purpose
For the HCH Care Coordination pilot, eight medical groups representing 85 individual clinics submitted
data for the Advance Care Planning measure. This report describes the validation processes used to
verify the data submitted and summarizes the results of the validation.
Validation Methods and Results
MNCM completed validation of the data in a three-step process: 1) denominator certification, 2) data
quality checks, and 3) validation audit. Details of this validation are described in this report.
1)Denominator Certification
In this initial step each medical group submitted a document outlining their method for identifying
patients age 65 or older who were seen by an eligible provider/specialty face-to-face at least two times
during the last two years prior to and including the pilot period (10/01/2011 to 09/30/2013) for any
reason by a certified health care home clinic, and seen at least one time for any reason during the pilot
period (07/01/2013 to 09/30/2013) by a certified health care home clinic.
MNCM staff verified each medical group’s method and system source code to ensure standard criteria
were followed and that eligible patients would be identified. MNCM contacted the medical group to
clarify their denominator method as necessary. In general, medical groups supplied complete
documentation for their denominator certification; only the following issues were found:
• Incomplete form (missing details or source code) – two medical groups
• Incorrect dates of service range – two medical groups
See the denominator certification template, Appendix C.
2)
Data Quality Checks
After the medical group identified the patients for the measure, collected the data per the data field
specification in the data collection guide, and submitted their data file to MNCM, quality checks of the
files were completed. The following checks were completed:
• Demographic data
o Race/Hispanic ethnicity, preferred language and country of origin (REL)
o Insurance information
• Dates of birth spanned the expected range (on or prior to 1948)
• Number of patients (denominator) was reasonable/expected
• Preliminary outcome rates that were lower on the spectrum of performance
No issues were found from the data quality checks, but MNCM contacted one medical group with the
lowest rate on the spectrum of groups’ performance. The group confirmed the preliminary rate, and we
© MN Community Measurement, 2014. All rights reserved.
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MNCM Health Care Homes- Care Coordination Advance Care Plan
(ACP) Complete Pilot Analysis and Results – April/May 2014
proceeded with the audit to verify the data they submitted. All other medical groups were audited as
well.
3)Validation Audit
After the data quality checks were completed, MNCM completed audits on all medical groups that
submitted for this pilot measure to verify the submitted clinical data. Listed below are the clinical data
elements audited. MNCM also verified the patient was seen in the in the pilot period and other
demographic data (e.g., REL).
• Advance Care Plan in the patient’s medical record includes the following:
o Patient’s wishes about future life-sustaining medical treatment
o Patient’s designated decision-maker, unless patient declines given the opportunity
• Reason for no Advance Care Plan as follows:
o Patient declined
o Discussion did not occur or unknown if discussion occurred
o Currently in process
MNCM used a standard validation process known as NCQA (National Committee for Quality Assurance)
“8 and 30”, described here:
In the NCQA “8 and 30” process, the first eight records are verified for accuracy and if no
errors are identified, the data is considered to be 100% compliant. If errors in the first
eight records are identified, we continue reviewing the total 30 records to identify any
error patterns or issues that may need correction.
Overall, medical groups passed the validation audit indicating that the data they submitted was accurate
and appropriate to use for rate calculation. One medical group missed reporting advance care plans in
some cases. They corrected their data and resubmitted. Two medical groups noted an issue with how
they coded “Do Not Resuscitate” (DNR) documentation. They coded DNR as a “Healthcare Directive”,
thus when they pulled the data, DNR was counted as an advance care plan.
The table below shows individual medical group audit results as well as information about their data
collection process:
Medical group
1.
Medical Group L
2.
Medical Group S
Audit details
Follow-up action
8 records reviewed, 8 records compliant (100%)
Additional information: Advance care plans are stored in the patient's
documents file and appears as either a healthcare directive or as a POLST. If
a healthcare directive or POLST is not listed in the patient's list of
documents, then the patient does not have an advanced care plan. The
form for a healthcare directive is broad and each patient can have a
different type of documentation (i.e. Honoring Choices, MN Healthcare
Directive, etc.)
8 records reviewed, 8 records compliant (100%)
Additional information: Per data collector, they did a quality measure with
their clinic on the POLST in the previous year so they have a system and
process down for getting those completed with patients and plan to
continue doing this for their patients. They document the patient's wishes
and decision maker in several places in their electronic system since many
of their patients have dementia and documenting it electronically makes it
© MN Community Measurement, 2014. All rights reserved.
March 2014
No further action
necessary; data is
compliant
No further action
necessary; data is
compliant
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MNCM Health Care Homes- Care Coordination Advance Care Plan
(ACP) Complete Pilot Analysis and Results – April/May 2014
3.
Medical Group T
4.
Medical Group B
5.
Medical Group
U
6.
Medical Group
V
7.
Medical Group
W
8.
Medical Group X
more easily accessible. They are a mobile geriatric clinic that primarily
works with older patients.
15 records reviewed, 12 records compliant (80%)
Additional information: During the audit, it came up that they had
submitted some patients as having an advance care plan but in the
patient’s record, it is actually a DNR/Resuscitation document only (no
designated decision maker addressed). Medical group stated that the
problem is because of the way they are coding the scanned documents. In
the patient’s record, the scanned healthcare directives are coded as
“Healthcare Directive/Code status”. The DNR/Resuscitation documents are
also being coded as “Healthcare Directive/Code status”. When data is
pulled, they are pulling dates and if a date comes up for that code, they
assume that the patient has a healthcare directive. Medical group states
that there isn’t a way for them to know if it is a healthcare directive or a
DNR/Resuscitation document without going into each patient’s file and
looking at the scanned documents. They do not know how many patients
are affected by this.
15 records reviewed, 14 records compliant (93%)
Additional information: During the audit audit, it came up that they had
submitted some patients as having an advance care plan but in the
patient’s record, it is actually a DNR/Resuscitation document only (no
designated decision maker addressed). Medical group stated that the
problem is because of the way they are coding the scanned documents. In
the patient’s record, the scanned healthcare directives are coded as
“Healthcare Directive/Code status”. The DNR/Resuscitation documents are
also being coded as “Healthcare Directive/Code status”. When data is
pulled, they are pulling dates and if a date comes up for that code, they
assume that the patient has a healthcare directive. Medical group states
that there isn’t a way for them to know if it is a healthcare directive or a
DNR/Resuscitation document without going into each patient’s file and
looking at the scanned documents. They do not know how many patients
are being affected by this.
30 records reviewed, 25 records compliant (83%)
Additional information: If the patient has an advance care plan, it appears
in the Advance Directive tab or in the patient document under the advance
directive folder or the health directive folder. There are several different
forms that can be used: Honoring Choices, MN Health Care Directive, Five
Wishes, etc. During the audit, we found that some of the plans did not get
pulled and submitted with the data because they were not put into the
correct folders.
8 records reviewed, 8 records compliant (100%)
Additional information: Advance care plans are captured and displayed in a
flowsheet format (ECH Ambulatory Intake process). Annually, their system
"updates" to inform the provider that plan is still in place. If the plan is
updated the new plan would display. Various plans used: Five Wishes,
Honoring Choices, POLST
8 records reviewed, 8 records compliant (100%)
Additional information: If an advanced care directive is available in the
patient's medical record, it will appear as "AD" (advanced directive) and
they can click on the link to view the paper copy of the plan that is scanned
in.
8 records reviewed, 8 records compliant (100%)
Additional information: Advance care directives are stored in the patient's
living will in their medical record. If an advance care directive was not
© MN Community Measurement, 2014. All rights reserved.
March 2014
No further action
necessary; DNR
issue noted
No further action
necessary; DNR
issue noted
Data was
resubmitted to
include missed
plans
No further action
necessary; data is
compliant
No further action
necessary; data is
compliant
No further action
necessary; data is
compliant
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MNCM Health Care Homes- Care Coordination Advance Care Plan
(ACP) Complete Pilot Analysis and Results – April/May 2014
present in the patient's living will, medical group looked in the patient's
Risk Screening Flowsheet where the patient indicated in a questionnaire
they declined to have an advance care plan. The medical group stated that
this measure wasn't too hard to pull. Verifying that the patient's advance
care plan addressed their wishes and a decision maker took more time
because they had to manually look at the scanned documents for those
items.
Summary
The validation process was successful in identifying errors and verifying the accuracy of the data
submitted by the participating pilot medical groups. MNCM recommends that the pilot data for this
measure be used for rate calculation and further data analysis with the consideration of the two medical
groups that coded DNR as a “Healthcare Directive”.
© MN Community Measurement, 2014. All rights reserved.
March 2014
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MNCM Health Care Homes- Care Coordination Advance Care Plan
(ACP) Complete Pilot Analysis and Results – April/May 2014
Appendix C – Denominator Certification
Template
© MN Community Measurement, 2014. All rights reserved.
March 2014
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MNCM Health Care Homes- Care Coordination Advance Care Plan
(ACP) Complete Pilot Analysis and Results – April/May 2014
© MN Community Measurement, 2014. All rights reserved.
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Health Care Homes Care Coordination Pilot Summary
Follow-up After Hospital Discharge
High level summary; please refer to full pilot report for more details
Numerator:
Percentage of patients with selected clinical conditions that have a follow-up telephonic/
electronic contact within three days of discharge OR a follow-up face-to-face visit with a health
care provider (physician, physician assistant, nurse practitioner, nurse, care-coordinator) within
seven days of hospital discharge.
Medical Group
Denominator: Adult patients who are discharged from the hospital during the
measurement period and have one of the following clinical
conditions:
Exclusions:
Pilot:

 Heart failure
 Pneumonia; age 65+
 Ischemic vascular disease
 Chronic obstructive pulmonary disease
Death during hospital stay, transferred to another acute or
transitional care facility after discharge, hospitalization is
observation status (hospital outpatient)
6 Medical Groups; 87 Clinics and 9,089 patients

Average rate of follow-up after discharge was 70.2%

Ranges by Medical Group (top graph) and by clinic (bottom graph)
demonstrate variability and some opportunity.

Majority of (~ 80%) patients meeting the numerator did so with a face to
face visit within 7 days of discharge. 24% of patients had a face-to-face
visit after telephonic contact.

19.5% of patients had only a telephonic/ electronic contact within 3 days;
of these, 99% were telephonic.

Most frequent interval between discharge and follow-up:
o Face-to-face within 2 days (n = 925)
o Telephonic within 1 day (n = 1,535)
Average number of days does demonstrate opportunity for improvement;
10.4 days for face-to-face and 9.5 days for telephonic

S
P
L
M
W
X
Overall Rate
Follow-Up After
Discharge Rate
90.3%
82.4%
72.4%
68.4%
64.6%
48.3%
70.2%

Telephonic encounter types proved difficult for some pilot participants; need more structure/
definition about what is acceptable to include.

Pilot demonstrated the impact of new Joint Commission hospital accreditation rules requiring the
transmission of transition of care record within 24 hours of discharge. Groups were pleasantly
surprised at the sudden turn-around in the timely receipt and the volume of notifications of discharge.

The denominator has an element of incompleteness in terms of a clinic knowing all of the potential
hospital discharges; the true data lies within the hospital’s data systems or a claims database and does
not naturally reside in the clinic’s data structure.

Pilot tested the feasibility of capturing readmission within 30 days; however this was optional because
it was recognized that this may prove difficult and related to the denominator constraints of a clinic
only being aware of discharges in which they are notified. Only two groups attempted to capture this;
results were inconclusive. Work group decided to focus on the care coordination and QI benefits of
the measure and not add unnecessary burden in the attempts to capture this outcome.
Health Care Homes Care Coordination Pilot Summary
Follow-up After Hospital Discharge

Groups are making their best efforts to capture all of the discharges that they are notified of in the
spirit of quality improvement, and some groups may do a better job of trying to capture discharges
outside of their system, but the efforts cannot be applied consistently and cannot hold side by side for
comparison.

Confirmed purpose of this measure; to promote coordination of care at a time during transition where
patients are more vulnerable. Measure is not suitable for consideration of accountability/ public
reporting or for use in benchmarking for health care home recertification.
Recommendation:
The measure development work group recommends that this measure be considered for use in quality
improvement and may be used for the purposes of health care home clinic evaluation and certification
processes. Due to the potential variability in the denominator based on group’s ability to capture discharges
that they are notified of; recommend that this measure not be used for purposes of benchmarking (clinic-toclinic comparison) for the health care home re-certification process.
Modifications: (made to specifications as a result of pilot)
 Groups will need to complete an attestation during the process denominator certification process for
telephone encounters that reflect the intent of the measure. If can’t attest to this, can’t submit telephone
encounters for numerator consideration.
 Attestation should include the further quantification of telephone encounters as those that occur between
the patient or family/ care giver and the telephone call is made for the purpose of follow-up after
hospitalization by a health care provider responsible for coordination of care (e.g. physician, physician
assistant, nurse practitioner, nurse, pharmacist, care coordinator or case manager). Guide will be updated
with this direction.
 Denominator certification process/ form to be enhanced to include attestation of including discharges from
both within and outside of care system.
 Field “Date Clinic Notified by Hospital of Discharge” will be designated as an optional field
 Fields removed as unnecessary following testing or removed due to data burden:
o Date Clinic Notified by Patient of Discharge
o Readmission within 30 days
Future Considerations:
In order to have a measure suitable for consideration of use for accountability or public reporting for follow-up
visits after hospitalization or hospital readmission; the best source of this information is an all payer claims
database which contains all hospital discharges, all visits regardless of location.
MNCM Health Care Homes- Care Coordination
Pilot Results- March 2014 Follow-Up After Hospital Discharge
Recommendation
The measure development work group recommends that this measure be considered for use in quality
improvement and may be used for the purposes of health care home clinic evaluation and certification
processes. Due to the potential variability in the denominator based on group’s ability to capture
discharges that they are notified of; recommend that this measure not be used for purposes of
benchmarking (clinic-to-clinic comparison) for the health care home re-certification process.
Modifications: (made to specifications as a result of pilot)
 Groups will need to complete an attestation during the process denominator certification process for
telephone encounters that reflect the intent of the measure. If can’t attest to this, can’t submit
telephone encounters for numerator consideration.
 Attestation should include the further quantification of telephone encounters as those that occur
between the patient or family/ care giver and the telephone call is made for the purpose of follow-up
after hospitalization by a health care provider responsible for coordination of care (e.g. physician,
physician assistant, nurse practitioner, nurse, pharmacist, care coordinator or case manager). Guide
will be updated with this direction.
 Denominator certification process/ form to be enhanced to include attestation of including discharges
from both within and outside of care system.
 Field “Date Clinic Notified by Hospital of Discharge” will be designated as an optional field
 Fields removed as unnecessary following testing or removed due to data burden:
o Date Clinic Notified by Patient of Discharge
o Readmission within 30 days
Future Considerations:
In order to have a measure suitable for consideration of use for accountability or public reporting for
follow-up visits after hospitalization or hospital readmission; the best source of this information is an all
payer claims database which contains all hospital discharges, all visits regardless of location.
Background
As part of a contractual relationship with the MN Department of Health (MDH) and the Health Care
Homes Division, MNCM was selected as a sub-contractor for the development of new measures for the
measure concept of care coordination. Measure development activities around this concept are
intended for the purposes of quality improvement and program evaluation and at this time there are no
current plans for use in public reporting. Following successful pilot completion and implementation for
health care homes clinics, there may be interest for inclusion in other programs.
The Measurement and Reporting Committee (MARC) reviewed the impact of potential measures for care
coordination and approved measure development activities for this topic. Of note, there is national
interest in developing more outcome measures, however it is recognized that the measure concept of
care coordination lends itself to measures that reflect the processes of care provided (medication
reconciliation, follow-up after referral to a specialist, contents of a hospital discharge summary or
continuity of care record, etc.) One of the challenges for the work group was to narrow the potential
topics of interest for care coordination and to design meaningful, feasible measures. Areas of care
coordination were explored and ranked by work group members as having the most impact on patient
© MN Community Measurement, 2014. All rights reserved.
March 2014
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MNCM Health Care Homes- Care Coordination
Pilot Results- March 2014 Follow-Up After Hospital Discharge
outcomes. In order of importance: communication and education, care transitions, patient experience,
medication reconciliation, provider to provider communication, access to care, care plans and
community collaboration. A sub-group met to explore potential process measures that would reflect
coordination of care and ultimately the work group decided on two individual measures; one for adults
age 65 and older reflecting documentation in the record of an advance care plan and the second for
adults with select conditions who are contacted within a certain number of days for follow-up after
hospital discharge.
Developmen
t Time Line
Task
Date/s
Research/ environmental scan for care coordination
August 2011
Impact presented at MARC, development approved
September 2011
Work group member recruitment
October/ November 2011
st
1 measure development meeting
nd
1/27/2012
rd
2 and 3 measure development meetings
3/1/2012, 3/27/2012
Sub- group for measure selection (meeting # 4)
5/11/2012
Meetings # 5, 6, and 7
July- October 2012
Measure specifications completed
November 2012
Public Comment
11/16 to 11/30/2012
Work group reconvene for redesign after public comment
1/10/2013
MARC approval for pilot of 2 measures
Pilot dates of hospital discharge (six months)- Follow-up
Hospital DC
2/13/2013
Data Submission- Follow-Up After Hospital Discharge
12/11/2013 to 1/10/2014
Validation audits- Follow-Up After Hospital Discharge
Jan/ February 2014
Survey Pilot Tools, Data and Burden
January 2014
Pilot analysis and re-convene
Feb/ March 2014
6/1/2013 to 11/30/2013
Pilot Goals/ Objectives-Follow-Up After Hospital Discharge
 Pilot to allow groups time to prepare for implementation dates of hospital discharge starting
6/1/2013
 Feasibility of capturing information about hospital discharges that may occur outside of a defined
health care system where electronic health records are not integrated. Understand the value of
improving communication processes that support the coordination of care for patients who are at
high risk of readmission following hospital discharge.
 Evaluate strength of proposed measures- rates demonstrate variability and results meet original
intent of the measures to promote the coordination of care through processes that support a
follow-up visit (face-to-face or telephonic/ electronic) after hospital discharge.
 Identify missing elements or components of measures.
 Record and track lessons learned. Share questions/ answers/ successes/ challenges via “list serv”
 Improve measure by incorporating feedback and providing clarification to improve data collection
guide and instructions.
© MN Community Measurement, 2014. All rights reserved.
March 2014
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MNCM Health Care Homes- Care Coordination
Pilot Results- March 2014 Follow-Up After Hospital Discharge

Facilitate work group discussion to address common challenges in collecting and reporting data.
Pilot Results- HCH Care Coordination Follow-Up After Hospital Discharge
Eight medical groups participated in the pilot submission for the Follow-Up After Hospital Discharge
Measure representing 109 clinic site locations. Following validation audits; six medical groups (87
clinics) had data that was suitable for analysis.
Race/Ethnicity
99.6%
capture; 0.4% blank
Demographics of Pilot Patients
N = 9,089 patients
52.3% male, 47.7% female
Race
White
Choose Not to Disclose
Asian
Black/ African Amer
Multiracial
Hispanic or Latino
American Indian/ Alaskan
Native Hawaiian/Pac Island
Some Other Race
Overall Total
Follow-Up
After Hospital
Discharge
5537
29
104
503
56
53
62
2
5
6351
Total
Patients
in Race
7843
49
164
740
79
77
90
4
5
9051
86.7%
0.5%
1.8%
8.2%
0.9%
0.9%
1.0%
<0.1%
<0.1%
Follow-Up After
Hospital DC
Rate
70.6%
59.2%
63.4%
68.0%
70.9%
68.8%
68.9%
50.0%
100.0%
70.2%
White
Choose not to Disclose
Asian
Black/African American
Multiracial
Hispanic or Latino
Am. Indian or Alaskan Native
Native Hawaiian/Pacific Isl.
Other Race
Measure: Follow-up After Hospital Discharge
Percentage of patients with selected clinical conditions that have a follow-up telephonic/ electronic
contact within three days of discharge OR a follow-up face-to-face visit with a health care provider
(physician, physician assistant, nurse practitioner, nurse, care-coordinator) within seven days of hospital
discharge.
Clinical conditions represent those with the highest volume of readmissions in MN1 and include:
•
•
•
•
Heart failure
Pneumonia; age 65+
Ischemic vascular disease
Chronic obstructive pulmonary disease
# of patients with select diagnoses and either a telephonic or electronic contact within 3 days
OR a follow-up face-to-face visit within 7 days of discharge
# patients age with selected diagnoses and hospital discharge in measurement period
1
MN Hospital Association Potentially Preventable Readmission (3M Software) Data for 2011
© MN Community Measurement, 2014. All rights reserved.
March 2014
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MNCM Health Care Homes- Care Coordination
Pilot Results- March 2014 Follow-Up After Hospital Discharge
Notes: Decision by the work group to not collect discrete data (individual fields) about the content of
the follow-up visit or to dictate what the content of the visit was; rather provided some
additional guidance about the recommended content covered during a post-hospital discharge
follow-up contact.
Follow-Up after Hospital Discharge Rates by Medical Group
(6 Medical Groups, 87 Clinics)
Medical Group
S
P
L
M
W
X
Overall Rate
Follow-Up After Discharge Rate
90.3%
82.4%
72.4%
68.4%
64.6%
48.3%
70.2%
Patients Submitted
31
17
5017
2940
1024
60
9089
© MN Community Measurement, 2014. All rights reserved.
March 2014
Please See Appendix
A for Blinded
Medical Group and
Clinic Rates
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MNCM Health Care Homes- Care Coordination
Pilot Results- March 2014 Follow-Up After Hospital Discharge
Follow-Up after Hospital Discharge Rates by Clinic
© MN Community Measurement, 2014. All rights reserved.
Please See
Appendix A for
Blinded
Medical Group
and Clinic
Rates
March 2014
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MNCM Health Care Homes- Care Coordination
Pilot Results- March 2014 Follow-Up After Hospital Discharge
Follow-Up after Hospital Discharge Rates by Follow-Up Type by Medical Group
Medical Group
N of
Numerator
Only via Face-toFace Within 7 Days
L
M
P
S
W
X
Overall Rate
3634
2012
14
28
662
29
6379
2807 (77.8%)
491 (24.4%)
5 (35.7%)
6 (21.4%)
233 (35.2%)
27 (93.1%)
3569 (55.9%)
Met via Face-to-Face Encounter [initial or eventual]
Only via
Telephonic/Electronic
Within 3 Days
162 (4.5%)
879 (43.7%)
1 (7.1%)
14 (50.0%)
188 (28.4%)
0 (0.0%)
1244 (19.5%)
Met via
Telephonic/Electronic and
Face-to-Face
665 (18.3%)
642 (31.9%)
8 (57.1%)
8 (28.6%)
241 (36.4%)
2 (6.9%)
1566 (24.5%)
5135 (80.5%)
Metric
Results
Number of Patients Submitted
9,089
Documentation of Race
99.9% (9051)
Documentation of Date Clinic Notified
by Hospital of Discharge
11.8% (1069)
Notes/ Thoughts
Groups were not able to reliably capture
this field; may have value for internal
quality improvement uses only. When they
did was often a date stamp related to a fax
and not necessarily an indication of
receipt/ reading or accepting. Suggest not
including this field/ measure moving
forward.
Face-to-Face Visit Type
1 = Office visit with primary care provider
2 = Office visit or consult with a specialist
3 = Care coordinator or nurse visit
4 = Home care visit
5 = Assisted living visit
6 = MTMS medication therapy management
Total Completed
77.7% (5409)
11.7% (815)
<1.0% (31)
8.9% (622)
<1.0% (28)
<1.0% (52)
76.5% (6957)
The majority of patients who did have a
follow-up contact after hospital discharge
contact type was a face-to-face contact;
56% had only a face-to-face, 24% had a
face-to-face after telephonic/ electronic
contact, resulting in ~ 80% of the patients
who did have contact had a face-to-face
type of contact.
Telephonic or Electronic Contact Type
1 = Telephone contact with patient/ caregiver
98.7% (4473)
Groups are in various stages of success in
capturing an actual telephone contact with
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March 2014
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MNCM Health Care Homes- Care Coordination
Pilot Results- March 2014 Follow-Up After Hospital Discharge
Metric
2 = Email contact with patient/caregiver
3 = Patient portal contact with patient/caregiver
4 = e-Visit with patient
Results
Notes/ Thoughts
0.7% (32)
0.5% (24)
0.1% (5)
the patient. Consider an attestation process
for groups to indicate that they are able to
differentiate type of contact and include
appropriately in order to be considered for
numerator compliance.
Total Completed
49.9% (4534)
Readmission within 30 Days
1 = Yes, readmitted within 7 days
2 = Yes, readmitted within 8 to 30 days
3 = No, not readmitted within 30 days
4 = Unknown
Total Completed
6.8% (413)
11.8% (715)
81.3% (4916)
0.0% (0)
66.5% (6044)
Documentation of Date Clinic Notified by Patient
of Discharge
<1.0% (3)
Note: This was an optional field; only two
groups were able to capture with any
consistency. See additional analysis on
page 8.
Note: This was an optional field; very few
groups were able to capture.
Number of Days Between Discharge and Face-to-Face Visit:
•
•
•
Range: 0 – 175 days
Average number of days = 10.4
Highest number of patients had two days between discharge and face-to-face follow-up
visit (n = 925)
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March 2014
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MNCM Health Care Homes- Care Coordination
Pilot Results- March 2014 Follow-Up After Hospital Discharge
Number of Days Between Discharge and Telephonic or Electronic Follow-up:
•
•
•
Range: 0 – 164 days
Average number of days = 9.5
Highest number of patients had one day between discharge and telephonic/electronic
follow-up (n = 1535)
Number of Days between Discharge and Date Clinic was Notified of Discharge (N = 1069)
Number of Days Between
Discharge and Date Clinic Notified
-1
0
1
2
3
4
Overall Total
Count
1
1057
5
4
1
1
1069
Some groups participating in the pilot did not attempt to
capture hospital discharges outside of their care system
because they did not have mechanisms in place to track
these patients.
Other groups, who had systems in place, were pleasantly
surprised at the number of notifications that they were
receiving from hospital facilities outside of their care
system. One group shares that 95% of their discharge
notifications from the hospitals were within 24 hours.
Groups cite new Joint Commission hospital accreditation
requirements for a transition of care summary within 24
hours as a potential reason for increased communication.
© MN Community Measurement, 2014. All rights reserved.
March 2014
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MNCM Health Care Homes- Care Coordination
Pilot Results- March 2014 Follow-Up After Hospital Discharge
Patients who Met Numerator Criteria for Follow-Up after Hospital Discharge that were
readmitted to Hospital within 30 Days (only using patients with Remission data)
Medical Group
L
N of Numerator
(had follow-up visit)
3634
Readmitted to
Hospital within 30
Days
605
30 Day Hospital
Remission Rate for
Numerator
16.6%
W
662
154
23.3%
M and X
NA/ Did not submit remission data (was optional)
P and S
Tried to capture but several blanks and small total n; included in total
Overall
4299
762
17.7%
Readmission Rates for Groups L and W
Total Submitted Population/ Follow-up Visit/ No Follow-up Visit
Understanding Potential for 30 Day Readmission
Total Patients
Group L
5017
# Readmissions in 30 Days
Group W
1024
L+W
6041
914
211
1125
Readmission Rate
18.2%
20.6%
18.6%
# Total Patients Who Had Follow-up Visit
# Patients with Follow-up and Readmission in 30 Days
3634
605
662
154
4296
759
Readmission Rate for Patients with Follow-up Visit
16.6%
23.3%
17.7%
Difference from Total Readmission Rate
- 1.6%
2.7%
-1.0%
# Total Patients Without Follow-up Visit
# Patients No Follow-up and Readmission in 30 Days
1383
309
362
57
1745
366
Readmission Rate for Patients and No Follow-up Visit
22.3%
15.7%
21.0%
Difference from Total
4.1%
-4.9%
2.4%
Thoughts:
Data collected during pilot phase about the impact of follow-up visits on readmission rates is
inconclusive. It appears that patients who have a follow-up visit/ contact after hospital discharge may
be less likely to be readmitted, but only two medical groups were able to provide consistent and
complete information about the occurrence of readmission within 30 days.
The follow-up after hospitalization measure has value and its own merit as a measure that focuses on
the coordination of care, the intent round which the measure was developed. The measure’s ability to
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MNCM Health Care Homes- Care Coordination
Pilot Results- March 2014 Follow-Up After Hospital Discharge
impact readmission rates would be considered secondarily, is worthy of future analysis, but the ability to
reliably capture the information is a barrier for using the information obtained as a reportable measure,
it should only be used internally. Barrier is to be able to cleanly identify the denominator (hospital
inpatients and the subsequent readmission hospital stay) from the clinic’s record system which is not
the source data for the hospitalization.
MNCM staff concludes that this field and the process of tracking 30 day readmissions when known may
have value to groups for internal reporting purposes only and should not be used for evaluations,
standardized benchmarking and comparison purposes for health care home clinics.
Readmissions are best captured utilizing an all payer claims database, which contains all hospitalizations
regardless of where they occur.
Results from Survey of Pilot Participants
Resource Use and Data Burden
Survey fielded from January 10th to January 17th, 2014 to all pilot participants (n = 136)
Received 6 responses (4.4 % response rate) representing 6 medical groups and includes mostly quality
improvement staff.
Survey respondents participating in the Advanced Care Measure: 6
Electronic Medical Record Capture
33.3% (2) – All data for submission extracted from EMR
66.7% (4) – Hybrid method (EMR and some manual abstraction)
0% (0) – Clinic has paper chart records; no EMR
Estimate of % Time Manually Abstracting Data
0%- all EMR
Estimate Hours to Program and Abstract Data
1 to 20%
1
Less than 20
20 to 40
21 to 40%
1
41 to 60
2
41 to 60%
61 to 80%
1
81 to 100
81 to 100%
1
101 or more
1
11 to 20
21 to 30
31 to 40
41 to 50
4
61 to 80
Estimate of Hours in Addition to Program
1 to 10
1
1
# of Staff for Collecting & Preparing Data
one
2
two
2
three
four
1
Five or more
51 +
3
2
1
Comments from medical groups about Follow-up After Hospital Discharge Measure:
• No additional comment provided by respondents
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MNCM Health Care Homes- Care Coordination
Pilot Results- March 2014 Follow-Up After Hospital Discharge
Easy
Difficult
Hospital Discharge Date
Very
Easy



Facility ID



Facility (Other) Description



Date Clinic Notified by Hospital of Discharge



Date Follow-up Face-to-Face Visit



Face-to-Face Visit Type



Date Telephonic or Electronic Contact



Telephonic or Electronic Contact type



Readmission within 30 days




Date Clinic Notified by Patient of Discharge




Data Element
Very
Difficult
Note: each  represents one response from a survey participant
Additional information from Survey:
Denominator
Q-23 How difficult was it for you to identify patients in the denominator for each condition?
All four conditions had the same ranking in terms of ease in identifying patients for inclusion; two
groups responding “very easy” and four medical groups responding “easy”.
Visit Types
Q-21 How difficult was it for you to identify the different types of face-to-face visits that occur?
Q-22 How difficult was it for you to identify the different types of telephonic or electronic visits?
Very
Easy

Easy
Difficult


Office Visit or Consult with Specialist



Care Coordinator or Nurse Visit



Home Care Visit

Assisted Living Visit
Visit Type
Office Visit with Primary Care Provider
Very
Difficult
Not
Applicable










MTMS Medication Therapy Management




Telephone



Email



Patient Portal



e-Visit



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MNCM Health Care Homes- Care Coordination
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Bright Spot: Even though survey results indicate a skew-ness towards higher ratings of
difficulty, we did observe groups making meaningful changes to their work flows, electronic
medical records and data collection. In the future, one might expect to see a shift towards
increased ease of data capture and extraction. One area that groups are working is related
to the creation of new telephone encounter types to capture care coordination activity.
Learning from Validation Audit: [Please refer to Appendix B for full report]
 Telephonic contacts were an area of difficulty for many groups with varying degrees of success for
including a telephone contact that actually occurred with the patient. Encounters types created for
the intent of telephone contact and labeled as such are often used as a mechanism for storing other
types of documentation, or can include a variety of types of calls that either do not involve the
patient at all (calls to the pharmacist, provider-to-provider calls) or do not meet the intent of
contacting the patient for follow-up purposes (lab result)
 Intent of including a telephonic or electronic contact was to be conscious of costs and not have a
measure require a face-to-face visit when care coordination can be accomplished by other means.
One area that the work group did not initially address in this health care home clinic based measure
was the consideration of hospital based care coordinator/ discharge coaches who are also following
up with the patient and do meet the care coordination intent of the measure.
 A few of the groups did not attempt to capture discharges outside their care system (owned
hospital/s), but were open to learning how other groups were successful incorporating this into their
work flows and EMR system; moving from scanned documents to reportable fields for discharges
 Groups very successful in capturing accurate hospital discharge date and hospital facility.
 Also successful in capturing face-to-face visits accurately and consistently.
 Those groups that were able to capture the date that they were notified did so with a date/ fax/
scan stamp which did not necessarily indicate receipt, reading or accepting.
Result of Validation Audits:
The validation process was successful in identifying errors and verifying the accuracy of the data
submitted by the participating pilot medical groups. MNCM recommends that the pilot data for this
measure be used for rate calculation and further data analysis with the exclusion of the data submitted
by the medical groups C, D, E noted above.
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MNCM Health Care Homes- Care Coordination
Pilot Results- March 2014 Follow-Up After Hospital Discharge
Appendix A
Display of Follow-Up after Hospital Discharge Rates
by Medical Group and Clinic; Blinded
Medical Group
Clinic ID
Follow-Up After Discharge Rate
L
054
85.1%
L
064
84.6%
L
069
84.6%
L
040
84.0%
L
059
78.9%
L
055
78.7%
L
058
78.4%
L
063
77.2%
L
044
77.0%
L
161
76.8%
L
048
76.5%
L
162
75.7%
L
070
74.8%
L
046
74.3%
L
068
74.3%
L
049
74.2%
L
060
73.7%
L
061
72.4%
L
052
71.8%
L
050
69.6%
L
062
69.0%
L
160
68.5%
L
056
68.4%
L
043
68.3%
L
057
67.9%
L
066
67.7%
L
047
67.5%
L
045
65.9%
L
053
65.8%
L
039
64.3%
L
042
63.9%
L
065
58.2%
L
051
57.1%
L
041
55.9%
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MNCM Health Care Homes- Care Coordination
Pilot Results- March 2014 Follow-Up After Hospital Discharge
L
071
L – Medical Group Total
52.5%
4%
M
078
72
100.0%
M
086
92.3%
M
093
88.2%
M
105
86.8%
M
087
83.3%
M
080
82.9%
M
085
82.9%
M
088
80.6%
M
103
80.0%
M
089
77.8%
M
081
76.9%
M
098
76.8%
M
101
74.6%
M
102
74.6%
M
077
74.1%
M
074
73.9%
M
079
73.8%
M
073
73.5%
M
095
72.7%
M
399
72.0%
M
099
71.0%
M
084
70.3%
M
109
69.4%
M
075
69.0%
M
076
68.8%
M
097
67.4%
M
092
66.9%
M
082
66.1%
M
107
65.4%
M
090
65.2%
M
108
65.2%
M
106
63.9%
M
096
62.7%
M
094
62.5%
M
091
61.6%
M
083
60.4%
M
100
55.4%
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MNCM Health Care Homes- Care Coordination
Pilot Results- March 2014 Follow-Up After Hospital Discharge
M
408
50.0%
M
104
50.0%
M – Medical Group Total
P
121
P – Medical Group Total
S
176
4%
68
82.4%
4%
82
90.3%
W
409
3%
90
90.7%
W
403
86.7%
W
406
74.5%
W
405
63.2%
W
410
62.1%
W
402
60.9%
W
404
56.4%
W
407
56.3%
W
400
50.0%
W
401
50.0%
S – Medical Group Total
W – Medical Group Total
X
175
X – Medical Group Total
Overall Rate
6%
64
48.3%
3%
48
70.2%
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MNCM Health Care Homes- Care Coordination
Pilot Results- March 2014 Follow-Up After Hospital Discharge
Appendix B
Validation Summary | Summary Report on the Validation Process for the HCH Care
Coordination Follow-up After Hospital Discharge| Pilot Dates of Service 6/01/2013 to
11/30/2013
Background and Purpose
For the HCH Care Coordination pilot, nine medical groups representing 109 individual clinics submitted data for the
Follow-up After Hospital Discharge measure. This report describes the validation processes used to verify the data
submitted and summarizes the results of the validation.
Validation Methods and Results
MNCM completed validation of the data in a three-step process: 1) denominator certification, 2) data quality
checks, and 3) validation audit. Details of this validation are described in this report.
1)
Denominator Certification
In this initial step each medical group submitted a document outlining their method for identifying patients age 18
or older with a qualifying diagnosis (heart failure, ischemic vascular disease, or COPD), and patients 65 or older
with a diagnosis if pneumonia. Also, the medical group described how they identified patients who were
hospitalized with an inpatient discharge date within the measurement period and who were seen by an eligible
provider/specialty face-to-face at least two times during the last two years prior to and including the pilot period
for any reason by a certified health care home clinic.
MNCM staff verified each medical group’s method and system source code to ensure standard criteria were
followed and that eligible patients would be identified. MNCM contacted the medical group to clarify their
denominator method as necessary. In general, medical groups supplied complete documentation for their
denominator certification; only the following issues were found:
•
•
Incomplete/missing diagnosis codes – one medical group
Incorrect visit criteria or dates of service – three medical groups
One medical group informed MNCM that they knew that some of the patients were not discharged home, rather
to other transitional care facilities. We opted to proceed with the audit to identify if any instances would be
identified. Of the eight records reviewed during the audit, all 8 (100%) were compliant and the patients were
discharged home. It was noted that this may be a limitation of the query, but the audit suggested that the
occurrence was infrequent.
See the denominator certification template, Appendix C.
2)
Data Quality Checks
After the medical group identified the patients for the measure, collected the data per the data field specifications
in the data collection guide, and submitted their data file to MNCM, quality checks of the files were completed.
The following checks were completed:
•
•
Demographic data
o Race/Hispanic ethnicity, preferred language and country of origin (REL)
o Insurance information
Dates of birth spanned the expected range (on or prior to 1995)
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MNCM Health Care Homes- Care Coordination
Pilot Results- March 2014 Follow-Up After Hospital Discharge
•
Verified that the file included patients with more than one discharge
No issues were found from the data quality checks, and MNCM proceeded to audit all medical groups to verify the
clinical data used to calculate preliminary outcome rates.
3)
Validation Audit
After the data quality checks were completed, MNCM completed audits on all medical groups that submitted for
this pilot measure to verify the submitted clinical data. Listed below are the clinical data elements audited.
MNCM also verified the patient had a qualifying diagnosis and was discharged home after the hospitalization (not
discharged to another transitional care facility).
•
•
•
•
•
•
•
Hospital discharge date
Facility patient discharged from
Date clinic was notified by the hospital of discharge (if submitted)
Date of face-to-face follow-up visit
Type of face-to-face visit
o Office visit with primary care provider
o Office visit or consult with a specialist
o Care coordinator or nurse visit
o Home care visit
o Assisted living visit
o Medication therapy management services (pharmacist)
Date of telephone or electronic contact
Type of telephone or electronic contact  contact implies that the patient was reached and participated
in the contact, not just a message left or sent
o Telephone contact
o Email contact
o Patient portal contact
o e-Visit with patient
MNCM used a standard validation process known as NCQA (National Committee for Quality Assurance) “8 and 30”,
described here:
In the NCQA “8 and 30” process, the first eight records are verified for accuracy and if no errors
are identified, the data is considered to be 100% compliant. If errors in the first eight records are
identified, we may continue reviewing the total 30 records to identify any error patterns or issues
that may need correction.
Prior to the audits, one metro integrated health system informed MNCM that they were able to identify discharges
that occurred both within their system as well as discharges from outside their system. As part of the validation
audit, MNCM also confirmed whether other medical groups were able to identify discharges from outside their
system and found that four medical groups who were part of an integrated health system included only discharges
from hospitals within their system. Although they have mechanisms to identify discharges from outside their
system, they did not include these in the submission for the pilot.
All nine medical groups were audited. Five medical groups passed the validation audit indicating that the data they
submitted was accurate and appropriate to use for rate calculation. Three medical groups had errors in the
telephone contact component. These groups were able to query their system for telephone contacts however upon
further review, it was found that the content of the calls was not always applicable for the intent of this
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MNCM Health Care Homes- Care Coordination
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measure. For example, some contacts were not initiated by the clinic, rather the patient or other entity initiated
the call to the clinic (incoming vs. outgoing calls), also some communications were between providers and the
patient was not involved in the communication. Identifying the content of the call would have required manual
review of the telephone contact. During one medical group audit, it was identified that they had included
discharges that did not qualify for the denominator. Emergency Department discharges were included in three of
the eight records reviewed which suggested that the denominator included discharges that did not qualify for the
measure. Following the audit they identified the outpatient (e.g., ED) discharges and removed them from the
population.
The table below shows individual medical group audit results as well as information about their data collection
process:
Medical group
1. Medical group A
2. Medical group B
3. Medical group C
4. Medical group D
Follow-up
action
Audit details
8 records reviewed, 8 records compliant (100%)
Additional information: In two records, the telephone contact was
not submitted because the information was scanned and not in a
structured field that could be queried. This limitation was noted
however the data is compliant for rate calculation and further
analysis. This medical group also informed MNCM about possible
discharges that were not to home (other transitional care facilities);
all eight records reviewed were compliant, indicating occurrence is
infrequent.
8 records reviewed, 8 records compliant (100%)
Additional information: This medical group primarily sees patients
who are in assisted living or memory care facilities. The discharge is
faxed from the hospital or from the nurse at assisted living facility to
the clinic. Care coordination occurs between clinicians and staff
at the assisted living - not directly with the patient or designated
caregiver. This is appropriate. Data submitter sometimes opted to
report later qualifying telephone contacts but could also have
reported specialist and care coordinator contacts. Some discharges
occurred on same day as the admission. Medical group could have
opted to exclude these visits if they were for observation only, but
since they were not able to easily identify these AND because these
patients were high-risk and would benefit from follow-up, it was
reasonable that they included these discharges. Medical group uses
a registry of discharges they are notified of and track follow-up
information. We used the registry during the audit but verified the
information in the patient record.
12 records reviewed, 5 records compliant (42%)
Additional information: These two medical groups shared an EMR,
therefore we audited a sample from one medical group and this
served as proxy for the other medical group’s data. Telephone
encounters were difficult to differentiate: incoming from patient or
facility vs. outgoing/outreach from clinic. Without manually
reviewing each telephone contact, they could not verify the content
of the calls.
© MN Community Measurement, 2014. All rights reserved.
March 2014
No further
action
necessary; data
is compliant
No further
action
necessary; data
is compliant
Data cannot be
used for
analysis;
telephone
contact data is
unreliable
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MNCM Health Care Homes- Care Coordination
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Medical group
5. Medical group E
6. Medical group F
7. Medical group G
8. Medical group H
9. Medical group I
Follow-up
action
Audit details
17 records reviewed, 7 records compliant (41%)
Additional information: This medical group misinterpreted that any
type of telephone contact that occurred, with or without the
patient, could be included. Some telephone contacts or RN notes
were included when there was not contact with the patient. Some
contact dates were also incorrect by a few days; incorrect dates
could impact rate calculation. One patient was also identified as
being discharged to a transitional care facility, not to home.
8 records reviewed, 3 records compliant (38%)
Additional information: Three of eight records were discharges
from Emergency Department encounters, not inpatient stays.
Some telephone contacts were questionable (e.g., patient’s
daughter initiated call, RN note about an advance care plan – not a
telephone contact, patient called asking about meds, patient’s
home care nurse initiated call to provider).
8 records reviewed, 6 records compliant (75%)
Additional information: Two patient records included telephone
contacts that did not qualify because the patient initiated the
phone call. They stated that they were able to differentiate calls in
which they actually spoke with the patient/caregiver versus calls in
which they did not connect (e.g., “left message”).
8 records reviewed, 8 records compliant (100%)
Additional information: This medical group created structured
fields (e.g., facility, admission date, discharge date, notification,
phone contact). Once the hospital notified the clinic of the discharge
(via central fax), a clinic staff entered the information into the
structured fields. Tasks were created to prompt the provider to
follow-up. For the audit, we were able to use a flowsheet that
displayed information from the structured fields as well as the
patient record. For the optional "Readmission" field, there was a
case in which one patient had two admissions and they assigned the
readmission code to the second admission rather than the first
admission. We clarified that the readmission code goes with the
first admission to indicate that the patient was readmitted within 7
days of the first admission.
30 records reviewed, 27 records compliant (90%)
Additional information: The medical group included all discharges,
including those in which the patient was not discharged home (e.g.,
nursing home). We reviewed all 30 records, and in two of the 30
reviewed, the patient was discharged to a nursing home. This
suggests the occurrence was low in the entire data set.
Data cannot be
used for
analysis;
telephone
contact data is
unreliable
Data was
resubmitted;
quality checks
completed;
data is
compliant
No further
action
necessary; data
is compliant
No further
action
necessary; data
is compliant
No further
action
necessary; data
is compliant
Conclusion
The validation process was successful in identifying errors and verifying the accuracy of the data submitted by the
participating pilot medical groups. MNCM recommends that the pilot data for this measure be used for rate
calculation and further data analysis with the exclusion of the data submitted by the medical groups C, D, E noted
above.
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MNCM Health Care Homes- Care Coordination
Pilot Results- March 2014 Follow-Up After Hospital Discharge
Appendix C – Denominator Certification Template
What information do I submit to MNCM for Denominator Certification?
Please submit a Word document to MNCM describing your process for identifying eligible
patients. A template and instructions are provided on the following pages.
How do I submit my document to MNCM?
1. Upload your document on the MNCM Data Portal, Denominator Certification section
2. After your document is submitted, MNCM will review your process and respond to you.
Please note: You are ultimately responsible for interpreting and applying the measure
specifications correctly.
a. If your document is complete and your process is verified, MNCM certifies your
denominator in the portal and you are notified by e-mail
b. If your document is incomplete or your process has errors, MNCM contacts you
directly to discuss next steps
What is the denominator? What is denominator certification?
Definition: The denominator is the bottom number in a fraction. In epidemiology, the
denominator represents a population group at risk of a specific disease.
Denominator Certification is an important first step in the data submission process. Medical
groups supply a written document that explains the process they use to identify eligible
patients for the measure. MNCM then reviews the documentation to verify the process will
identify eligible patients correctly.
What are the criteria for identifying eligible patients for the denominator?
Please refer to the Denominator section of the measure specifications for details about the
criteria for identifying eligible patients for the denominator.
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MNCM Health Care Homes- Care Coordination
Pilot Results- March 2014 Follow-Up After Hospital Discharge
1. Insert this table in a Word document and complete the requested information
Denominator document
instructions
1. Medical group information
Supply the following information:
2. Patients age 18 and older
Enter the start date used to identify
patients who are 18 and older with
diagnoses of heart failure, ischemic
vascular disease and COPD.
Highlight this details you provide in
section 2 below.
3. Patients age 65 and older with
diagnosis of pneumonia
Highlight this details you provide in
section 2 below.
Your response
2013 Measure: [Enter measure name]
Medical group name: [Enter medical group name]
Your name: [Enter your name]
Your phone number: [Enter your phone number
Your email address: [Enter your email]
Name of your medical director, administrator or lead: [Enter name of
medical director, administrator or lead]
The following start date is used for patient’s date of birth:
[MM/DD/YYYY]
For patients without heart failure, ischemic vascular disease or COPD who
have a diagnosis of pneumonia, only include those patients who are 65 and
older.
The following start date is used for patient’s date of birth with the
diagnosis of pneumonia:
[MM/DD/YYYY]
4. Diagnoses
Indicate how patients with one more
diagnoses are identified: heart
failure, pneumonia, ischemic
vascular disease, or COPD
Highlight this details you provide in
section 2 below.
5. Hospitalization
It is an acceptable strategy to identify all four diagnoses for 18 and older
and then to limit those patients with only pneumonia to 65 and older.
All diagnosis codes listed in the measure specification tables are queried as
follows (select one):
 Diagnosis in principal or secondary position (billing), or
 Diagnosis on active problem list (electronic record)
(Show codes in source code or written description in section 2 below.)
Describe how patients with a hospitalization with an inpatient discharge
date within the measurement period are identified:
[Describe here]
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MNCM Health Care Homes- Care Coordination
Pilot Results- March 2014 Follow-Up After Hospital Discharge
Denominator document
instructions
6. Patients established in the health
care home clinic(s)
Enter the date range used to identify
patients who are established in the
health care home clinic(s).
You attest that you will count visits
according to the denominator
specifications.
Highlight this details you provide in
section 2 below.
Your response
We use the following criteria to identify patients who are established in the
health care homes clinic(s):
The following date range will identify patients seen by an eligible
provider in an eligible specialty face-to-face two or more times during
the last two years prior to and including the pilot period for any reason
by a certified health care home clinic:
[MM/DD/YYYY TO MM/DD/YYYY]
For medical groups that have a mix of certified health care homes and nonhealth care home clinics, please indicate that you used the special
attribution instructions indicated in the data collection guide and describe
your process.
[if applicable, enter description of process here]
REMINDER about your total number of eligible patients: Later in the data submission process, you will enter the
total number of eligible patients (denominator) in the portal, therefore it’s necessary to determine your eligible
population correctly. You must remove patients who do not meet the visit criteria from the population. If you do
not remove these patients from the population, the denominator is not accurate. For example, if your list includes
all patients age 18 and older with a diagnosis and appropriate hospitalization, but you did not remove patients
who do not meet the visit criteria, the denominator is not accurate.
7. Eligible clinics, specialties and
The following are the certified health care home clinic(s:
providers:
You attest that you will include only
[Enter the clinic names here]
certified health care home clinics
and eligible specialties and providers These are the eligible specialties and provider types:
according to the measure
specifications.
[Enter the specialty/ies in your practice that are applicable for this
measure]
Highlight this detail in the source
[Enter the provider type/s in your practice that are applicable for this
code you provide (step 2 below).
measure]
8. Allowable Exclusions
Describe how patients with an allowable exclusion are removed from the
population:
Patient died during hospital stay: [Describe here]
Patient transferred from hospital to acute/transitional care: [Describe
here]
Patient in hospital for observation/outpatient only: [Describe here]
© MN Community Measurement, 2014. All rights reserved.
March 2014
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MNCM Health Care Homes- Care Coordination
Pilot Results- March 2014 Follow-Up After Hospital Discharge
Denominator document
instructions
9. Other attestations
• Read each attestation
carefully.
• You must agree to all
attestations before you
submit your denominator.
• By submitting this
document, you are
indicating that you agree
with these attestations.
Please contact MNCM if
you have any questions.
Your response
1.
2.
3.
4.
5.
6.
7.
We agree to apply the denominator criteria in the measure
specifications correctly. We acknowledge that we are ultimately
responsible for interpreting and applying the measure
specifications correctly in our query.
We agree to identify and remove any patients duplicated on the
patient list.
We agree to exclude patients with an allowable exclusion only. We
agree to include all patients who meet the age and established
patient criteria based on visits in the denominator. We will not
exclude patients for any subjective reason.
We agree to include patients who are not active patients if they
are eligible based on the measure criteria (i.e., we will include
patients whose status is “inactive” or patients who have
transferred care).
Include one of the following attestations
o We agree to submit our full population of eligible
patients.
o We agree to use one of the sampling methods described
in the data collection guide to randomly select patients.
We agree to complete the Quality Checks of our data file prior to
submission per instructions in the data collection guide.
Our medical director, administrator or other lead can attest that
the specifications will be followed and all eligible patients
included.
2. Supply source code or written description
1. Query your record system for eligible patients for this measure. Maintain the source
code.
2. Copy and paste the source code into the Word document.
3. Highlight information for the MNCM reviewer (e.g., dates, visit counts, CPT/ICD-9/V
codes as applicable, eligible specialties and providers, exclusions as applicable):
Cannot supply source code? Please provide a written description of your process. You may
include screen shots that demonstrate to the MNCM reviewer that you have applied the
correct parameters to your query (e.g., dates, codes).
© MN Community Measurement, 2014. All rights reserved.
March 2014
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