Centre for Research in Geriatric Medicine

Centre for Research in Geriatric Medicine

DEVELOPMENT OF DEVELOPMENT OF QUALITY INDICATORS FOR QUALITY INDICATORS FOR

OLDER PEOPLE IN OLDER PEOPLE IN TRANSITION CARETRANSITION CARE

DEVELOPMENT OF DEVELOPMENT OF QUALITY INDICATORS FOR QUALITY INDICATORS FOR

OLDER PEOPLE IN OLDER PEOPLE IN TRANSITION CARETRANSITION CARE

Centre for Research in Geriatric Medicine

Investigators & FundingInvestigators & Funding

Investigators– Professor Len Gray, The University of Queensland

– Professor Ian Cameron, University of Sydney

– Professor Maria Crotty, Flinders University

– Dr Nancye Peel, The University of Queensland

Consultants– Professor John Morris, Hebrew Senior Life, Boston, USA

– Professor Richard Jones, Harvard Medical School, Boston, USA

Funding– NHMRC Health Services Research Program Grant 2006-11

Centre for Research in Geriatric Medicine

Research AimsResearch Aims

To develop and validate a suite of Quality Indicators (QIs) applicable to older persons in transition from acute care to the community

To undertake an economic analysis to assess the clinical outcomes and resource implications of the program.

Centre for Research in Geriatric Medicine

Why Quality Indicators?Why Quality Indicators?

Internal monitoring of quality, basis for quality improvement strategies

Inter-service benchmarking Quality monitoring by funding

agencies Public accountability, including

aiding consumer choice

Need

for

greater accu

racy

Centre for Research in Geriatric Medicine

Target Audience(s) Target Audience(s)

Programs– Complex community based post acute programs, serving

older people

Stakeholders– Primarily service providers and their staff

– Secondary audiences• Funders of services• Consumers

Designed for international relevance

Centre for Research in Geriatric Medicine

Criteria for high quality QIsCriteria for high quality QIs

Indicators conform with expert opinion of good outcomes

Indicators reflect best evidence of good outcomes Based on robust, reliable observations Prevalence > 5% & < 95% Accommodate variation in caseload between

services (risk adjusted) Discriminate between best and worst performing

services Can be collected at low cost

Centre for Research in Geriatric Medicine

Three broad categories of QIsThree broad categories of QIs

Outcome Indicators- focus on what is achieved o Examine direct outcomes of care

Process Indicators- focus on what is doneo Examine whether processes are conducted at an

individual level which are known to be associated with good outcomes

Structural Indicators- focus on what is neededo Examine the policies, resources, design features, etc, at

an organisational level to ensure appropriate care process and outcomes

Centre for Research in Geriatric Medicine

QI focus in TCP study QI focus in TCP study

To develop and validate “outcome oriented” QIs for older people in transition care. ( A set of QIs has been developed in North America based on interRAI Home Care assessments)

To compare above with the assessments of quality derived from process indicators. (A set of process QIs, ACOVE 3, ‐has recently been developed in the USA for community‐dwelling vulnerable elders).

To explore predictors of quality among participating transition care program sites

To examine the cost of collection of each format of QIs

Centre for Research in Geriatric Medicine

Study Plan: Phase 1Study Plan: Phase 1

Development of a Provisional Set of QIs Develop draft QI set based on literature review, best practice

guidelines pertaining to geriatric outcomes in post acute/ subacute care

Review by Expert Panel (geriatricians, rehabilitation specialists, allied health practitioners, service providers, research academics, policy analysts)

Refine to conceptualise a set of QIs for the TCP derived from the interRAI HC and ACOVE 3 systems and available administrative data

Centre for Research in Geriatric Medicine

The Expert Panel: ObjectivesThe Expert Panel: Objectives

Workshop 1 (May 2009)– To review clinical domains of importance to older people in

transition care

– To establish best practice (based on published evidence and expert opinion) for care of older patients in transition care

– To advise on potential QIs to underpin data collection in the Field Study

Workshop 2 (Nov 2010)– To examine results of the field study and provide advice on

final QI data set(s)

Centre for Research in Geriatric Medicine

QI domainsQI domains

Physical functioning, falls and mobility Cognition and emotional health Social functioning Nutrition Medication & pain management Skin integrity & continence Continuity of care & goal attainment

Centre for Research in Geriatric Medicine

QI Examples QI Examples

Domain QI Type Denominator Numerator

Physical Function Failure to improve/ incidence of decline in self-care Activities of Daily Living (ADL)

Outcome All clients Clients who have some impairment on ADL and who fail to improve/remain the same on discharge or who develop a new ADL impairment

Physical Function Assessment of physical function at admission

Process All clients Clients with documented evidence of objective physical function assessment (including self-care) using a validated tool (eg Modified Bartel Index; Katz; FIM) within 24 hours of admission

Centre for Research in Geriatric Medicine

Study Plan: Phase 2Study Plan: Phase 2

Field testing 6 community-based TC sites, 2 states (QLD & SA),

approx 400 cases Collecting prospective clinical data using interRAI HC

assessment for outcome QIs Completing a file audit for process QIs (based on

ACOVE QIs)

Centre for Research in Geriatric Medicine

Study Plan- Phase 3 Study Plan- Phase 3

Analysis and final consultation QIs adjusted for ascertainment and selection bias

through risk adjustment procedures expert panel reconvened to consider the findings of

the field study, and assembly of the final QI set and associated recommendations.

site coordinators will be invited to a final consultation meeting for an opportunity to contribute to the quality framework and benchmarking for their programs.

preparation of a formal report in addition to publications for the peer-reviewed literature