Mandatory State-wide Universal Transfer Form: The New Jersey Experience

1. October 10, 2007 Session: T - 4 8am to 9am Mandatory State-wide Universal Transfer Form: The New Jersey Experience Presented By Daniel Moles, RN, BBA, MPS, LNHA Director of Quality Improvement / Clinical Services Health Care Association of New Jersey (HCANJ) dan@hcanj.org (609) 890-8700

2. New Jersey Demographics • 3rd smallest state • 8th largest G.D.P. • Population: 8.9million • Median Age: 39.1 years • Over 75 = 6.6% 590,000 • Diverse Demographics • Urban • New York City • Philadelphia • Suburban • Rural Farmland

3. Universal Transfer Form (UTF)[aka] Continuity of Care Document (CCD) • What is it? • What is its origin? • How did it develop? • What worked – what didn’t? • What next in New Jersey? • Should your state do it?

4. Continuity of Care Document (CCD) • A state-wide, mandatory use “transfer form” • Inpatient / resident transfers between licensed health care facilities and programs. • Selective exclusions: • Emergency Dept. \]Emergency Dept. • Emergency Dept. \] Return to LTC • New Born, Others

5. What’s in a Name? • Universal Transfer Form (UTF) • Common understanding of established terms • Task centered • Form centered • Continuity of Care Document (CCD) • New term • National term • Patient / Resident centered

6. Origin of CCD • Past Unsuccessful Attempts: • Wide-spread Recognition of Opportunity:

7. All Volunteer Task Force(partial list)

8. Advantages of Universal CCD • Communications between providers • Efficiency of process • Quality of care at transition • Patient / resident / family satisfaction Work Smarter, Not Harder, It’s Easier!

9. CCD and The Electronic Health Record (EHR) • Greater need to “Highlight” essential information at transfer. • Data Dump / Information Overload • NJ CCD - EHR User “Friendly” • Future Plan • Harvest CCD content from EHR • “Instant” CCD

10. NJ CCD Highlights • Two Pages (may change) • Page one – Essential information • Page two – Desirable information • No Duplication: Attach related documents • Reason(s) for transfer • Follow-up care / appointment details • Decision Maker: Identity/Contact Information • If questions, who to call? • Name • Number

11. NJ CCD Pilot Test • Phase One : Initial Brief Trial • Phase Two: • Funded by CMP dollars • 4 - 7 months • NJ State University Research Team • Project Coordinator • Diverse, representative sample • Well-organized feedback

12. New Jersey Continuity of Care Document (CCD) Draft

13. CONTINUITY OF CARE DOCUMENT UNIVERSAL TRANSFER FORM (08/2007) TRANSFER FROM (Facility/Program): _____________________________________________________________ _____________________________________________________________ Place label here (Facility/Program) TRANSFER TO (Facility/Program): _______________________________________________________ _______________________________________________________ Date of transfer________________________________________

17. NJ CCD: How / When Mandatory? • NJ State DHSS Regulation • Lead time: Future Effective Date • Mandatory for: • Hospitals (inpatient) • Long-Term Care: SNF, Sub-acute, ALF • Home Care • Process to Modify / Improve • Exclusions: • Emergency Department Emergency Department • Newborns • Others • Training in regional locations

18. What NJ did right • Avoid these goofs NJ CCD Highlights

19. Clear Purpose: Patients’ right to continuity of care Broad outreach to stake holders Transparent, democratic process Trial “test drive” Initial Formal – arms length Get it right the first time Prioritize content: less is more Selective exclusions Power over purpose Force the issue Elite, closed door strategy No “test drive” Don’t let the “perfect” halt the “good” NJ CCD Development Process What Worked What To Avoid

20. Federal C.M.S. – P.A.C. • Uniform Patient Assessment Form

21. C.M.S. – P.A.C. – P.R.D. • Post Acute Care – Payment Reform Demonstration • Mandated by Deficit Reduction Act 2005 • P.A.C. – P.R.D. Goals • Recommendations for Medicare payment reform • Identify discharge placement patterns • Evaluate Patient Outcomes across settings • Report to Congress 2011

22. C.M.S. – P.A.C. – P.R.D. • Data collection tools • C. A. R. E.: Continuity Assessment Record and Evaluation • Health / Functional Status Assessment • C. R. U.: Cost Resource Utilization • Costs and resources tool • More information at: www.cms.hhs.gov/SNFPPS • Click on “Post Acute Care Reform Plan.”

23. Open Discussion Questions and Comments

24. Closing Comment New Jersey Universal Transfer Form: In New Jersey, providers, regulators and professionals agreed to focus on onemajor improvement to substantially help the greatest number of people.