Metrics Definition - Transition Planning

Transition Planning Norm

Connect Care provides decision and documentation supports that can help clinicians with transition planning, while improving communication with healthcare providers picking up care after discharge. These tools comprise a "transitions planning package" that helps with:

Appropriate and timely use of transition planning tools during inpatient encounters is among the Connect Care Meaningful Use Norms.

Transition Planning Metrics

Expected Discharge Date

An inpatient's Expected Discharge Date (EDD) (also referred to as "Estimated" or "Anticipated" discharge date) is the approximate day that the patient should be ready to transition to the next care setting, including community settings. The EDD may reflect awareness of an Expected Length of Stay (ELOS) for patients with the same admitting diagnosis, demographics and co-morbidity burden, but the EDD is a date and the ELOS is an interval.

The EDD Entry Metric is the proportion of hospital acute care inpatient encounters where the EDD is entered (including "unknown" selections) by the admitting hospital service within 48 hours of the time of signing the admission order for the inpatient encounter. Meaningful Use Norms stipulate that an EDD should be entered within 24 hours of the time of entry of the inpatient admission order. 

The EDD Review Metric is the proportion of hospital acute care inpatient encounters where the EDD is updated or reviewed by the discharging hospital service within 72, 48 and 24 hours of the actual discharge time. Periodic revision of EDDs for all inpatient encounters is among the Connect Care Meaningful Use Norms.

Transition Planning Interactive Reports

Rapid Rounds patient lists, interactive patient list reports, interactive planning sidebar displays and interactive documentation blocks are some of the many tools that can facilitate transition planning during inpatient encounters. 

The Transition Care Plan Metric is the proportion of hospital acute care inpatient encounters where the post-discharge needs data element has been interacted with.

Discharge Readiness Traffic Lights

Rapid Rounds patient lists and reports, as well as chart sidebar transition planning displays, provide access to interactive discharge readiness "Traffic Lights" that provide at-a-glance overviews of patient readiness from the perspective of health disciplines participating in discharge planning. A Smart Data Element is activated if the Traffic Lights have been used during an encounter.

The Discharge Planning Reviewed Metric is the proportion of hospital acute care inpatient encounters where the Discharge Readiness Traffic Lights have been used at least once.

Of note, the use of the Discharge Planning SmartForm is encouraged, however, teams might have different processes set up for RAPID rounds. Therefore, this metric is recommended for teams that use the SmartForm consistently, ideally daily.

Workflow

Transition Planning Meaningful Use Norms and Workflows are described in the Connect Care Clinician Manual.

Expected Discharge Date

A first EDD entry can be entered in a variety of ways, including via an admission navigator, admission order, or admitting history & physical documentation. The same data can be reviewed and revised via admission and discharge navigators, sidebar popups, patient list popups, discharge planning popups and discharge orders.

The most recently revised EDD value is exposed for users in a variety of places within patient lists, reporting workbench reports and inpatient charts. 

Transition Care Plan

Rapid Rounds patient lists, interactive patient list reports, interactive planning sidebar displays and interactive documentation blocks are some of the many tools that can facilitate transition planning during inpatient encounters by displaying a consistent transition planning report. Users can review and click-to-edit key details about patient supports pre-admission, current needs and barriers to discharge and anticipated community needs. All make use of structured data that all inpatient disciplines have agreed to use, sharing the burden of data entry and maintenance. The transition care plan details can be pulled into discharge documentation to the extent justified by the complexity of discharge needs.

Discharge Readiness

Rapid Rounds patient lists and reports, as well as chart sidebar transition planning displays, provide access to interactive discharge readiness "Traffic Lights" that provide at-a-glance overviews of patient readiness from the perspective of health disciplines participating in discharge planning. The visual display further supports click-to-edit so that disciplines can quickly revise their readiness determinations.

Data

Transition Planning management is supported in Connect Care (Epic) with diverse data elements. 

Metrics

EDD Entry

Description

When multiples values are entered, the most recent value is counted. Exception is “Marked as Reviewed” which is counted if it’s the only entry. If other values exist (either EDD Entered or Unknown), it is excluded from the numerator.

Denominator

Numerator

Calculation

Grouping (Denominator Subsets)

Analytics Definitions

EDD Review

Description

Denominator

Numerator

Calculation

Grouping (Denominator Subsets)

Analytics Definitions

Transition Planning Report


Discharge Planning Reviewed

Description

Denominator

Numerator

Calculation

Grouping (Denominator Subsets)

Analytics Definitions

Limitations

Attributable Change

EDD Metrics will most closely reflect meaningful use norm compliance when the responsible hospital service has trained, organized and supported its staff in recommended workflows. If EDD-aware discharge planning occurs, but the EDD field is not used, or some alternate toolkit is used within or outside Connect Care, then changes to EDD processes and outcomes will not be attributable to standard EDD tool use.

EDD Metrics do not capture information about the use of related information tools (e.g., EDD Comments, Discharge Readiness indicators, Discharge Milestones, Discharge Delays, Discharge Checklists and Flowsheets) that may be as or more important to efficient inpatient flows.

EDD Metrics do not reflect whether EDD information is communicated to patients and families, and how this might impact discharge readiness.

Further development may allow filtering by the type of provider scribing EDD entry or revision and the care context.

Validity

The current AHS configuration assumes that EDDs are estimated and manually entered by providers, reflecting their best understanding of when discharge can occur. The EDD is used, dynamically, to calculate an expected length of stay (ELOS) which is synchronously updated in the ELOS data variable. 

However, ELOS is normally understood to be a standards-based estimate of a patient's expected length of stay for a particular admitting diagnosis, adjusted for demographics, patient co-morbidity and national medians. AHS uses CIHI data to generate a-priori ELOS values based on standard reference tables. At some future date, this information (or an acceptable surrogate) may be used to automatically set the entry EDD at admission. The Connect Care configuration would be changed, deriving the initial admitting ELOS, and so EDD, from reference tables.  Providers would then have opportunity to make adjustments as knowledge and circumstances change during an admission.

Given the current AHS configuration -- generating ELOS from EDD rather than EDD from ELOS -- these metrics should be understood as triggers for discussion and planning. It is the discussion and planning behaviours that are expected to improve patient flow; not the actual EDD value which is, at best, an informal experience-informed guess.

Timeliness

EDD Entry Metrics are currently calculated for admitted or discharged patients (discharged patients only for EDD Review metrics), are retrospective (or delayed by several hours for admitted patients), and so do not necessarily help with current hospital service inpatient flow or discharge planning. The metric can help teams set goals for behavior (meaningful use) and process changes but cannot be used for real-time observation of behavior change.

User Interface Variation

A variety of user interfaces and tools are available for entering and changing EDD values in Connect Care. Those that are part of Epic Foundation have little to no embedded help or decision supports. 

Newer AHS SmartForms and Navigators with EDD editing features draw more attention to time intervals to an EDD that are clinically meaningful for discharge planning. Users who take advantage of those tools will be more likely to have actual EDD values set (rather than "unknown" which nullifies data but is tempting to use in Epic interfaces) but precise dates will be less meaningful than date ranges, with the EDD precision increasing as the actual discharge date approaches.

Practice Variation

Confusion about appropriate use of the "unknown" button in some EDD user interfaces has led to null EDD values for most inpatients in many settings. There is currently difference of opinion, and so inconsistent meaning of EDD data, about how dates should be estimated, whether intervals should be used and when it is appropriate to click the "unknown" button.

System - Facility Incongruences

It is easiest to group EDD data by inpatient ward (Epic "department"). However, Epic presently handles Emergency Inpatients (EIPs) as belonging to the Emergency Department. AHS typically operates at 100%+ bed occupancy and so it is also typical for patient to be admitted to hospital but associated with the emergency department for a day or more. This makes is more difficult to interpret the EDD Entry metric when trying to attribute to a clinically meaningful inpatient service and location.

Work is underway to improve filtering by an admitting inpatient service.

Transition Planning Report

The metric uses a single flowsheet row (encounter level) that is set if the discharge plan is interacted with at the level of a patient's destination (post-discharge needs). The state of this row is initially null until any member of the team interacts with the transition planning report, or one of its supporting flowsheets, to indicate whether the patient's support needs will change (yes or no) from pre-admission needs. 

Inpatient teams that have not been initiated to, or are not resourced for, discharge planning reports (available from lists, Rapid Rounds and chart sidebar) may not be aware and so never interact with the tool. Despite this, they may have effective transition planning processes.

Discharge Readiness Traffic Lights

The metric uses a single Smart Data Element (encounter level) that is set when the discharge readiness planning tool is used. The state of this variable is initially null and remains so until a determination about medical readiness for discharge is entered. Since overall readiness indicator is dependent upon this value, a non-null value is a decent surrogate for tool use. Of course it reflects nothing of quality or effectiveness of discharge readiness discussions.

Inpatient teams that have not been initiated to the discharge readiness report (available from lists, Rapid Rounds and chart sidebar) may not be aware and so never interact with the tool. Despite this, they may have effective transition planning processes.

Reports

Radar Dashboards

Reporting Workbench

Slicer-Dicer

Components

Planning is supported in Connect Care (Epic) with a wide range of documentation, listing and reporting components that are used in many workflows.

Resources