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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)
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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
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
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?
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
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
Origin of CCD • Past Unsuccessful Attempts: • Wide-spread Recognition of Opportunity:
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!
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
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
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
New Jersey Continuity of Care Document (CCD) Draft
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________________________________________
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
What NJ did right • Avoid these goofs NJ CCD Highlights
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
Federal C.M.S. – P.A.C. • Uniform Patient Assessment Form
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
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.”
Open Discussion Questions and Comments
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.