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					                                                                                                                        The National Quality Forum
                                                                             Comments on Draft Report: National Voluntary Consensus Standards for Care Coordination

#   Member              Organization                   Topic
    Status                Contact                                                                                                                Comment                                                                                                         Proposed Action
    Member       Barbara Rudolph, The       General            The Leapfrog Group supports the National Quality Forum's efforts to address the lack of care coordination evident in our current healthcare delivery environment. The      Comment for which no action can be taken. NQF recognizes
                 Leapfrog Group                                Leapfrog Group also supports the effort to develop a comprehensive framework for care coordination measurement. However, the devil is in the details, in particular, the the importance of outcome measures and other NQF projects
                                                               use of terminology that is limiting in terms of application of these metrics. We hope that the National Quality Forum would broaden these preferred practices to all       are currently addressing this issue
                                                               licensed healthcare providers who are delivering "primary care" to patients. In addition, we hope that NQF will quickly address the need for linkage of these practices to
                                                               the outcomes of care. We would like NQF to avoid the same journey through process measures that has occurred with hospital and physician measures.


    Member       Barbara Rudolph, The       General            The Leapfrog Group is concerned that checkboxes will be developed to indicate that the patient was given information about their medications and about their plan of         Comment for which no action can be taken
                 Leapfrog Group                                care. As we have seen with tobacco cessation counseling, this will likely not change the actual way patients receive care and will not resolve the care coordination issues.
                                                               For meaningful change, the preferred practices must focus on care outcomes as quickly as possible. To that end, the Leapfrog Group provides comments on specific
                                                               practices that need further attention.

    Member       Bernard M. Rosof,          General            The Physician Consortium for Performance Improvement® appreciates the opportunity to comment on the National Quality Forum’s (NQF) Endorsing Preferred                           The link was inadvertently ommitted. Links to the code sets will
                 Physician Consortium for                      Practices and Performance Measures for Measuring and Reporting Care Coordination report. While we support this report and its goals of improving care coordination,              be provided if available, but not all measures center around
                 Performance Improvement                       we would like to express a broader concern with a trend in this report and others in which measures appear to lack full specifications (eg, ICD-9 CM, CPT®). The                 ICD-9 CM or CPT. Measure developers have reviewed this
                                                               inclusion of the applicable specifications and coding allows for consistent implementation across providers as well as transparency in measure definitions. Lack of              comment and, as applicable, ensure the specifications are
                                                               specificity inhibits the use of performance measures as a source to guide consistent and appropriate care. We encourage the NQF to reiterate the importance of                   complete, and if applicable, ICD-9 CM or CPT codes supplied
                                                               including specifications for all measures when measures are evaluated.

    Non-Member   Bonnie Sanderson, Auburn   General            Extremely timely and important report that provides direction and a focused path in improving quality of care through care coordination. It is especially important to           Comment supports draft report
                 University                                    include the expectation for research in evaluating the effectiveness of the performance measures.


    Non-Member   Carol Gleason, CMSA        General            The Steering Committee notes on pg 5 the emphasized need for furthur research to evaluate practices across providers/settings. I certaily agree.                                 No action necessary
                 Member                                        I do not feel suggestions will be quickly implemented in the Medical Home. I would expect high costs to coordinate across all settings, especially if providing 24 hr
                                                               response.

    Non-Member   Carol Gleason, CMSA        General            I do not feel all of these measures are part of a CM daily practice. Until electronic health records (EHR)are the standard for all and all members of the "Home"use the          No action necessary
                 Member                                        same application, registering and monitoring activity would be labor intensive. I do not see it improving CM outcomes. Measuring redirection of pts, while possibly
                                                               helpful, will be difficult to implement and sustain.

    Member       Carol Sakala, Childbirth   General            Childbirth Connection expresses appreciation to NQF for giving priority to care coordination and its measurement. This is a crucial area for improving the quality,              Comment for which no action can be taken
                 Connection                                    outcomes and value of health care. . While supportive, we express concern about the focus on health care home. This does not benefit those who currently lack access
                                                               to the health care home model. We feel that many of the measures are applicable more broadly across health care settings. All health care settings should be
                                                               accountable for strong care coordination.

    Member       Carol Sakala, Childbirth   General            We also request NQF and its care coordination team to consider whether the data can be stratified by race/ethnicity, language, payment source, and gender for                    Comment incorporated into draft report
                 Connection                                    measuring disparities in care coordination.

    Member       Carol Sakala, Childbirth   General            Further, we express continuing concern about the need to measure outcomes of care coordination and leverage performance measurement results to improve                           Committee and NQF recognize the important of outcome
                 Connection                                    outcomes.                                                                                                                                                                        measures and other NQF projects are addressing this issue


    Member       Carol Sakala, Childbirth   General            Finally, we recognize that care coordinate applies broadly to all areas of health care and hope that it might be possible to identify generic measures, for example relating Committee and NQF recognize the important of outcome
                 Connection                                    to communication of test results, to avoid the complexity and burden of multiple specific measures for the same purpose.                                                     measures and other NQF projects are addressing this issue


    Member       Catherine MacLean,         General            We are in lign with the comments made by the steering committee. No additional comments to add. Thank you.                                                                       Comment for which no action can be taken
                 WellPoint Inc.


    Non-Member   Charles Willmarth, American General           Occupational therapy practitioners bring a unique skill set and expertise that can and should be a vital component of any new or existing care coordination models to            Comment for which no action can be taken
                 Occupational Therapy                          achieve optimal client outcomes and deliver more targeted, effective care. Occupational therapy addresses issues of daily living that are often ignored but are critical to
                 Association                                   care coordination and maintaining healthy habits, particularly for individuals with chronic conditions. Occupational therapy is particularly effective in addressing children
                                                               with disabilities like autism in school or in other settings (American Journal of Occupational Therapy, 2008) or families addressing Alzheimer’s disease (The
                                                               Gerontologist, 2000).

                                                               AOTA respectfully requests that the role of occupational therapy be recognized in Preferred Practices 6, 9 and 10 with regard to lifestyle therapy, education and
                                                               counseling activities and participation in life and community activities:

    Member       Cheri Lattimer, CMSA       General            On behalf of the 12,000 members of the Case Management Society of America, I want to commend the Care Coordination Steering Committee on their efforts to               Comment for which no action can be taken
                                                               improve patient safety, consumer satisfaction, and the health of our nation through standardizing and measuring care coordination. Case management is the corner
                                                               stone of care coordination and our members understand the challenges this committee faced as they searched for measures and practices that are evidenced-based. As
                                                               your document indicates, many were called but few were chosen. This scarcity of data and research in the literature only emphasizes the need for this committee and the
                                                               National Quality Forum to continue this work.

    Member       Cheri Lattimer, CMSA       General            As our members reviewed the 10 measures selected, we were struck by the fact that none of the measures fit the criteria for what our association considers care            Committee and NQF recognize this is a starting point for a
                                                               coordination. At best, some of the measures are looking at indicators of appropriate follow up treatments for certain services or procedures which should rightly be       care coordination measurement set, and the measures will
                                                               covered under the individual specialty’s practice guidelines. It would have been good to see measures around medication reconciliation, transitions of care, and care plan evolve as the field evolves.
                                                               documentation and adherence -areas I think we all agree are essential components of care coordination.


    Member       Cheri Lattimer, CMSA       General            Many of our members felt that they knew of many measures that are being used in the field and several best practices but were not submitted to your Committee.                   Comment for which no action can be taken in the report. NQF
                                                               Perhaps a re-examination of how your calls for measures are promoted and the complexity of the existing submission process are in order.                                         widely disseminates the call for measures and practices.
                                                                                                                                                                                                                                                Regarding the complexity, NQF does require specific
                                                                                                                                                                                                                                                information and documentation, but this process has evolved
                                                                                                                                                                                                                                                for standardization and rigor purposes.
    Member       Cheri Lattimer, CMSA       General            On a review of the proposed practices, it also appeared that only a small percentage of practices submitted met the committee’s criteria for acceptance. Perhaps this            Committee and NQF recognize this set of practices is a
                                                               speaks to the fact that there still isn’t clarity about what care coordination is and who should be responsible for doing care coordination and what credentials should this     starting point for a care coordination, and the practices will
                                                               person possess. CMSA is about to release its revised Standards of Practice for 2010. We will be happy to send the members of this committee copies.                              evolve as the field evolves.



    Member       Cheri Lattimer, CMSA       General            We also want to commend the committee for the practice standards they are proposing that include criteria for care plans, responsible parties, and patient and caregiver Comment supports draft report
                                                               participation. We are also pleased to see that the committee understood the need to have a licensed health care professional oversee the care coordination piece. It
                                                               was also reassuring to see that the National Transitions of Care Coalition’s work was referred to in your deliberations.


    Member       Cheri Lattimer, CMSA       General            Encouraged by the NQF Care Coordination Steering Committee’s work, and inspired by the lack of research present in the literature, the CMSA Research and                 Comment for which no action can be taken
                                                               Outcomes Committee is creating new awards designed to identified and acknowledge providers doing research in the areas of case management, care coordination and
                                                               transitions of care. We hope that this new award will help CMSA identify measures and practices being used in the field today that will be appropriate for consideration
                                                               by NQF in future rounds of calls for care coordination measures and practices.




    Member       Christine Chen, Pacific    General            The Pacific Business Group on Health supports the National Quality Forum’s efforts at developing a portfolio of measures around the extremely important subject of               No action taken. Practices currently reflect a team-based
                 Business Group on Health                      care coordination. As has become clear over the last several years, care coordination is a critical component of improving health care outcomes and bending the cost             approach, with the exception of a few physician-focused
                                                               curve, particularly for those patients with multiple conditions who seek care from a variety of providers across multiple specialties. We would like to see the report reflect   practices, in addition, practice 5 focuses on care coordination
                                                               the fact that care coordination for persons with multiple chronic conditions, especially older adults, should be team-based, integrating both health care and social service     services for patients with adverse health outcomes, high
                                                               supports. Older adults with multiple chronic conditions also often have functional and/or cognitive impairments and need linkages to home and community-based services           service use and high costs.
                                                               and supports as part of comprehensive care coordination

    Member       Christine Chen, Pacific    General            While the practices as a whole do provide a comprehensive framework for providers to follow in improving care coordination efforts, we do have comments and                      The healthcare home is clearly a distinct domain endorsed by
                 Business Group on Health                      concerns on specific practices, provided below. In general, we feel that defining a set of practices as relating to the healthcare home does a disservice to consumers for       NQF, and as such, specific practices related to that are key.
                                                               whom the healthcare home model is not currently available. The practices in this domain should be applied to all health care settings, not just the healthcare home. The         Nothing in the report indicates that these practices are limited
                                                               healthcare home is a model that is built upon care coordination as a foundational aspect of care delivery, but patients in all delivery systems should be ideally be             to the healthcare home and are prohibited from implementation
                                                               receiving at least a minimum level of care coordination. As daunting a task as was developing the preferred practices for care coordination, the question now will be how        in other settings. For other domains, the report makes clear
                                                               to translate these practices into performance metrics that will provide consumers and purchasers with information on which providers are actually meeting these care             (e.g., plan of care), that the practices apply to all care settings.
                                                               coordination goals.

    Member       Christine Chen, Pacific    General            As daunting a task as was developing the preferred practices for care coordination, the question now will be how to translate these practices into performance metrics           No action necessary. The report does recognize that it will be
                 Business Group on Health                      that will provide consumers and purchasers with information on which providers are actually meeting these care coordination goals.                                               important to develop a more robust set of performance
                                                                                                                                                                                                                                                measures.
    Member       Christine Chen, Pacific    General            In terms of the measures that are recommended for endorsement, while some reflect an understanding of the 360 degree nature of care coordination – which requires                comment incorporated into draft report
                 Business Group on Health                      engagement by the patient, the provider, the institution, the laboratory, and the community – others appear less rigorous and it is unclear how they would improve
                                                               coordination of care. More detailed comments are provided for specific measures. A general comment across all the measures that we would ask the developers to
                                                               answer is whether the data can be stratified by race and gender in order to identify disparities in care coordination activity.

    Member       Christine Chen, Pacific    General            A broader question for NQF is to consider how care coordination measures can be linked to outcome measures. For example, medication reconciliation and                           Committee and NQF recognize the important of outcome
                 Business Group on Health                      transmission of transition records are both important process steps toward reducing readmission rates. In order to strengthen consumers’ and purchasers’ ability to              measures and other NQF projects are addressing this issue
                                                               understand how care coordination relates to other care metrics, we strongly suggest NQF pursue a strategy for linking care coordination and outcomes measures.

    Member       Christine Chen, Pacific    General            Finally, it should be noted that care coordination issues that cut across specialties and/or providers (e.g. test results that involve a referring doctor and a specialist)      No action taken. Committee and NQF recognize the need for
                 Business Group on Health                      should have a standard measure framework applied to them. In other words, instead of having multiple measures related to communicating test resutls, all of which                these measures, but this is a starting point for a care
                                                               pertain to specific tests and/or conditions, there should be one broad-based measure in this area that can apply across specialties. We strongly urge NQF to take a              coordination measurement set, and the measures will evolve as
                                                               strong leadership role in crafting a framework of preferred practices that will drive this.                                                                                      the field evolves. The emphasis within the practices on the
                                                                                                                                                                                                                                                team will hopefully drive such broad-based measures.

    Non-Member   Deborah Gutteridge, MS,    General            Firstly, may I take this opportunity to congratulate the NQF committee on their efforts with this most challenging project. As a case manager, I realize how difficult it can    no action taken. The committee recognizes that the measures
                 Mentor ABI Network                            be to identify specific measures, especially regarding coordination of care. To that end, as a case manager who could be effected by the possible mandatory                      are a first step for addressing care coordination and the focus
                                                               implementation of the recommended measures for standards for care coordination, I specifically gave more attention to that area. The measures not adopted are                    is not on any one provider
                                                               indeed not measures of care coordination, but my concern is that the measures the committee did recommend are simple actions, and not indiciative of true care
                                                               coordination. I would recommend stronger verbage to include "case management" and use of the "care plan." As these measures presently stand, they are NOT
                                                               indicative of true care coordination measures. The missing mechanism seems to be the "how" the coordination occurs, which is through the involvement of case
                                                               management and involvement in the care plan. I hope I am making my viewpoint clear, and encourage the inclusion of the mechanism of case management for true care
                                                               coordination be included in future efforts.

    Member       Debra Ness, National      General             The National Partnership for Women & Families is very pleased to see the National Quality Forum’s expand its portfolio of preferred practices around                         Comment supports draft report
                 Partnership for Women and                     care coordination, and work to endorse a set of measures on this extremely important subject. As evidenced by the work of the National Priorities Partnership, care
                 Families                                      coordination is a critical component of improving health care outcomes and bending the cost curve. The presence or absence of high
                                                               quality care coordination can be a defining element of whether a patient is readmitted to an in-patient setting, something which has major repercussions for the patient,
                                                               their family, and the health care system as a whole. This is particularly true for those patients with multiple conditions who seek care from a variety of providers across
                                                               multiple specialties. Care coordination for persons with multiple chronic conditions, especially older adults, should be team-based, integrating both health care and social
                                                               service supports. In addition, older adults with multiple chronic conditions also often have functional and/or cognitive impairments and need linkages to home and
                                                               community-based services and supports as part of comprehensive care coordination.


    Member       Debra Ness, National      General             Our biggest concern regarding the preferred practices is the way in which they are organized. It would appear that a subset of practices is meant to guide how care is           The healthcare home is clearly a distinct domain endorsed by
                 Partnership for Women and                     coordinated only in a healthcare home setting. This needs to be broadened. Defining a set of practices as relating only to the healthcare home does a disservice to              NQF, and as such, specific practices related to that are key.
                 Families                                      consumers for whom the healthcare home model is not currently available. Care coordination practices should be applied to all health care settings. Another concern is           Nothing in the report indicates that these practices are limited
                                                               how these practices will be translated into performance metrics. As daunting a task as was developing the preferred practices for care coordination, we believe that             to the healthcare home and are prohibited from implementation
                                                               without performance metrics, consumers will not have information on which providers are actually meeting these care coordination goals, and subsequently on where                in other settings. For other domains, the report makes it clear
                                                               they may find care that performs to the highest standards of quality. There needs to be some acknowledgement of this issue, and a discussion of where to go from here            (e.g., plan of care), that the practices apply to all care settings.
                                                               so that the hard work put into developing these practices does not go unnoticed.

    Member       Debra Ness, National      General             In terms of the measures that are recommended for endorsement, we are pleased to see some measures that reflect the communication breakdown that occurs between No action taken. Committee and NQF recognize the need for
                 Partnership for Women and                     primary care providers and specialists, particularly in the area of lab test results. In order for true care coordination to occur, there must be engagement among all these measures, but this is a starting point for a care
                 Families                                      parties, including the patient, the provider, the institution, the laboratory, and the community. Not all the measures put forward for endorsement meet that standard. coordination measurement set, and the measures will evolve as
                                                               Some appear much less rigorous in their specification, and it is truly unclear how they would serve to improve coordination of care.                                   the field evolves. The Committee only advanced measures for
                                                                                                                                                                                                                                      which communication loops clearly were closed.

    Member       Debra Ness, National      General             In addition, please clarify whether the data collected by all of these measures can be stratified by race and gender in order to identify disparities in care coordination       Comment incorporated into draft report
                 Partnership for Women and                     activity.
                 Families


                                                                                                                             NQF DRAFT: DO NOT CITE, QUOTE, REPRODUCE, OR CIRCULATE                                                                                                                                    1
Member       Barbara Rudolph, The         General   The Leapfrog Group supports the National Quality Forum's efforts to address the lack of care coordination evident in our current healthcare delivery environment. The      Comment for which no action can be taken. NQF recognizes
             Leapfrog Group                         Leapfrog Group also supports the effort to develop a comprehensive framework for care coordination measurement. However, the devil is in the details, in particular, the the importance of outcome measures and other NQF projects
                                                    use of terminology that is limiting in terms of application of these metrics. We hope that the National Quality Forum would broaden these preferred practices to all       are currently addressing this issue
                                                    licensed healthcare providers who are delivering "primary care" to patients. In addition, we hope that NQF will quickly address the need for linkage of these practices to
                                                    the outcomes of care. We would like NQF to avoid the same journey through process measures that has occurred with hospital and physician measures.


Member       Debra Ness, National      General      Finally, we pose two broader questions for NQF to consider. First, how can we link care coordination measures to outcome measures. For example, medication                       Committee and NQF recognize the importance of outcome
             Partnership for Women and              reconciliation and transmission of transition records are both important process steps toward reducing readmission rates. In order to strengthen consumers’ and                  measures and other NQF projects are addressing this issue
             Families                               purchasers’ ability to understand how care coordination relates to other care metrics, we strongly suggest NQF pursue a strategy for linking care coordination and
                                                    outcomes measures.

Member       Debra Ness, National      General      Second, it should be noted – in the final report and elsewhere – that care coordination issues which cut across specialties and/or providers (e.g. test results that involve Comment incorporated into draft report. Changes were made
             Partnership for Women and              a referring doctor and a specialist) should have a standard measure framework applied to hem. In other words, instead of having multiple measures related to                 to the practice statement, incorporating the term 'specialist
             Families                               communicating test results, all of which pertain to specific tests and or conditions, there should be one broad-based measure in this area that can apply across             provider' to represent other providers, such as nurses and case
                                                    specialties. We strongly urge NQF to take a strong leadership role in crafting a framework of preferred practices that will drive this.                                      managers, who may be directly involved in patient care.


Non-member   Ellen Kurtzman, The George General     The term ―medical home‖ is limited in the use of physicians as providers of coordinated, primary care whereas the term ―health home‖ is inclusive of all primary care         Report was reviewed to assess whether the terms were clearly
             Washington University,                 practitioners. Additionally, the two terms are not interchangeable despite the report’s suggestion that they are (lines 217-219). So, for consistency, the term ―health home‖ delineated; medical home was only used when others used it to
             Department of Nursing                  – a widely accepted term -- should be used throughout the report.                                                                                                             describe their work. The language stating that the report
             Education                                                                                                                                                                                                            utilizes the terms interchangeably was modifed to clarify that
                                                                                                                                                                                                                                  NQF uses the broader term healthcare home, but relied on the
                                                                                                                                                                                                                                  evidence from medical home at this time until additional
                                                                                                                                                                                                                                  implementation and research can be conducted.

Non-member   Ellen Kurtzman, The George General     Throughout the document primary care is limited used to physician care (e.g., primary care physician) and fails to acknowledge that nurse practitioners often serve in           The use of primary care physician is confined to
             Washington University,                 primary care roles. Alternatively, the term ―primary care practitioners‖ or ―primary care providers‖ should be used throughout the report.                                       implementation examples or references in which it was clear
             Department of Nursing                                                                                                                                                                                                   that a physician was needed for implementation. When it was
             Education                                                                                                                                                                                                               within our control we used more generic terms for care
                                                                                                                                                                                                                                     providers, except for a few physician-focused practices.


Non-member   Ellen Kurtzman, The George General     The term ―plan of care‖ is used throughout the report yet never defined. In some cases this term appears to refer to medical services only; in others it applies to a            No action taken. The specifications of practice 6 articulate the
             Washington University,                 broader definition that includes community and non-clinical services. A clear definition of plan of care including its essential components should be established in this        essential components of the plan of care
             Department of Nursing                  report.
             Education
Non-member   Ellen Kurtzman, The George General     Practices 1-5 are dependent on the availability of the health home to all patients and in all geographic areas. Currently, the health home is merely a concept and does not No action taken. The committee recognized that some
             Washington University,                 exist widely in practice. As a result, establishing practices as NVCS that are dependent on what is merely a concept is not actionable/implementable for providers. So, in practices are stretch goals, but felt that it was appropriate at
             Department of Nursing                  the absence of widely available health homes, the report should clearly convey that providers should be expected to adopt preferred practices 6-25.                         this time to advance the state of the field. The committee felt
             Education                                                                                                                                                                                                          that organizations will implement the practices in a manner that
                                                                                                                                                                                                                                best fits their needs and resources.
Non-member   Ellen Kurtzman, The George General     Throughout the report, the performance measurement recommendations supporting the preferred practices are inconsistent with the very principles established by NQF No action taken. The commentor did not mention the fourth
             Washington University,                 – i.e., measures that address outcomes, composites, and focus on disparities. This inconsistency should be addressed either by recommending measures that address strategic direction , "drive toward high performance." Given the
             Department of Nursing                  these high priorities or excluding any recommended measures that fails to address these priorities.                                                                         current state of measures development, the performance
             Education                                                                                                                                                                                                          measures recommended in this report are focused on that,
                                                                                                                                                                                                                                while we recognize that outcome measures, composites and
                                                                                                                                                                                                                                disparities are important, they are not available at this time.
                                                                                                                                                                                                                                NQF is however currently working toward other projects to
                                                                                                                                                                                                                                address outcome and composite measures.


Non-member   Ellen Kurtzman, The George   General   • Page 13, Line 211 -- As stated, this suggests that the health home has been proven (e.g., tested) which is not the case. Delete the term ―proven‖                              Comment incorporated into draft report
             Washington University,
             Department of Nursing
             Education
Non-member   Ellen Kurtzman, The George   General   Page 14, Line 235 -- The sentence starts with ―other models‖ but then simply reverts to content related to the medical home. Delete ―other models such as‖                       Comment incorporated into draft report
             Washington University,
             Department of Nursing
             Education
Non-member   Ellen Kurtzman, The George   General   Page 20, Line 407 --―balance measures for quality outcomes‖ is not clear. Clarify this statement.                                                                                Further clarification was provided in report. The statemment
             Washington University,                                                                                                                                                                                                  was referring to measures focused on outcomes
             Department of Nursing
             Education
Non-member   Ellen Kurtzman, The George   General   Page 41, Line 1044-1045 -- ―…who is admitted to the hospital will experience a transition…‖While this is true, what is more accurate is that ―…who receive inpatient care        No action taken
             Washington University,                 of any type will experience a transition…‖
             Department of Nursing
             Education

Non-member   Ellen Kurtzman, The George General      Page 41, Line 1052 -- These health care professionals should be accountable for transitional care services. Please modify to read: ―…the availability of healthcare             Comment incorporated into draft report
             Washington University,                 professionals who are accountable for transitions and who are well trained….‖
             Department of Nursing
             Education

Non-member   Ellen Kurtzman, The George General     Page 42, Line 1056 -- It is not just physicians who work in silos. Modify to read: ―…are evident, health care practitioners often work in silos…‖                                Comment incorporated into draft report
             Washington University,
             Department of Nursing
             Education

Member       Ellen Schwalentocker,        General   On behalf of the nations childrens hospitals, which are committed to excellence in providing care to children and their families, the National Association of Childrens         Comment supports draft report
             NACHRI                                 Hospitals and Related Institutions (NACHRI) is pleased to comment on the draft report, Endorsing Preferred Practices and Performance Measures for Measuring and
                                                    Reporting Care Coordination: A Consensus Report. This report addresses a critically important area. NACHRI is in agreement with many of the comments submitted
                                                    separately by the American Academy of Pediatrics and the National Association of Pediatric Nurse Practitioners as well as comments submitted electronically by Family
                                                    Voices. Coordination of care for all children and, especially, children with special health care needs is vitally important. Children with special health care needs often have
                                                    multiple chronic conditions, and they and their families require coordination across many specialists and settings. We join the AAP and NAP/NAP in urging the NQF to
                                                    insert the words child/youth/adult and family wherever possible and to broaden the definition of transitions of care. We also encourage the incorporation of the example
                                                    implementation approaches provided by these organizations as the Steering Committee sees fit.


Member       Ellen Schwalentocker,        General   A minor comment, but the wording of the practices is somewhat inconsistent. Most practices are stated in should terms; some are worded as will or shall and one                  Consistent wording within the practices was addressed. Where
             NACHRI                                 practice is worded differently (i.e., 14).                                                                                                                                       "should or will is used," the flexibility imparted through those
                                                                                                                                                                                                                                     words is intended. Where "shall" is used, the intent is
                                                                                                                                                                                                                                     "mandatory"

Member       Ellen Schwalentocker,        General   Finally, it may well be beyond the scope of this project and the role of the National Quality Forum, but it would be refreshing to see a policy practice in which the roles of   Comment for which no action can be taken
             NACHRI                                 all stakeholders in the healthcare system, including the role of payers in aligning payment with care coordination were explicitly recognized as a standard.


Member       Ellen Schwalentocker,        General   With regard to the measures, please ensure that ages, inclusions and exclusions are appropriately documented for each measure.                                                   Comment accepted. A final review for the accuracy of the
             NACHRI                                                                                                                                                                                                                  measures was performed.



Member       Gayle Fortner, HC21          General   Care coordination is a critical component of improving health care outcomes and bending the cost curve. I hope to see the report reflect that care coordination for              No action taken. The report clearly makes reference to the
                                                    persons with multiple chronic conditions, especially older adults, should be team-based, integrating both health care and social service supports.                               health team and support



Member       Gayle Fortner, HC21          General   A general comment across all the measures is whether the data can be stratified by race and gender in order to identify disparities in care coordination activity.               Comment incorporated into report



Member       Gayle Fortner, HC21          General   Please consider how care coordination measures can be linked to outcome measures. Medication reconciliation and transmission of transition records are both                      No action taken. NQF currently has a project underway to
                                                    important process steps toward reducing readmission rates. In order to strengthen consumers’ and purchasers’ ability to understand how care coordination relates to              address outcome measures
                                                    other care metrics, I strongly suggest NQF pursue a strategy for linking care coordination and outcomes measures.

Member       Gayle Fortner, HC21          General   Finally, it should be noted that care coordination issues that cut across specialties and/or providers (e.g. test results that involve a referring doctor and a specialist)      No action taken. Committee and NQF recognize the need for
                                                    should have a standard measure framework applied to them. In other words, instead of having multiple measures related to communicating test results, all of which                these measures, but this is a starting point for a care
                                                    pertain to specific tests and or conditions, there should be one broad-based measure in this area that can apply across specialties. I urge NQF to take a leadership role        coordination measurement set, and the measures will evolve as
                                                    in crafting a framework of preferred practices that will drive this.                                                                                                             the field evolves. The emphasis within the practices on the
                                                                                                                                                                                                                                     team will hopefully drive such broad-based measures.

Member       Gayle Fortner, HC21          General   Information System Domain: In line 933 of the introduction to this domain, I have concerns about the use of the word ―integrated.‖ It should be clearly stated that the          Comment incorporated into draft report
                                                    information systems used to assist with care coordination should include web applications and other mobile applications (such as those developed for an iPhone
                                                    platform). These are the most likely ways consumers and patients will be able to access electronic health information, and therefore the information systems
                                                    acknowledged as part of the Coordination of Care framework should not exclude those consumer-facing technologies. In general, EHRs and PHRs are only two
                                                    examples of the particular types of technology that are necessary for care coordination. Limiting discussion to only those two technologies will present a barrier for
                                                    effective use of HIT in care coordination.

Member       Geraldine Bednash, AACN      General   AACN would like to endorse and support the following comments set forth by Ellen Kurtzman. General Comments: Terminology - The term ―medical home‖ is limited in                 Report was reviewed to assess whether the terms were clearly
                                                    the use of physicians as providers of coordinated, primary care whereas the term ―health home‖ is inclusive of all primary care practitioners. Additionally, the two terms       delineated; medical home was only used when others used it to
                                                    are not interchangeable despite the report’s suggestion that they are (lines 217-219). So, for consistency, the term ―health home‖ – a widely accepted term -- should be         describe their work. The language stating that the report
                                                    used throughout the report.                                                                                                                                                      utilizes the terms interchangeably was modifed to clarify that
                                                                                                                                                                                                                                     NQF uses the broader term healthcare home, but relied on the
                                                                                                                                                                                                                                     evidence from medical home at this time until additional
                                                                                                                                                                                                                                     implementation and research can be conducted.


Member       Geraldine Bednash, AACN      General   Throughout the document primary care is limited used to physician care (e.g., primary care physician) and fails to acknowledge that nurse practitioners often serve in       The use of primary care physician is confined to
                                                    primary care roles. Alternatively, the term ―primary care practitioners‖ or ―primary care providers‖ should be used throughout the report.                                   implementation examples or references in which it was clear
                                                                                                                                                                                                                                 that a physician was needed. When it was within our control we
                                                                                                                                                                                                                                 used the more generic of those terms except for a few
                                                                                                                                                                                                                                 physician-focused practices.
Member       Geraldine Bednash, AACN      General   The terminology ―plan of care‖ is used throughout the report yet never defined. In some cases this term appears to refer to medical services only; in others it applies to a No action taken. The specifications of practice 6 articulate the
                                                    broader definition that includes community and non-clinical services. A clear definition of plan of care including its essential components                                  essential components of the plan of care


Member       Geraldine Bednash, AACN      General   AACN would like to endorse and support the following comments set forth by Ellen Kurtzman. Thank you. General Comment: Concepts                                             No action taken. The committee recognized that some
                                                    Practices 1-5 are dependent on the availability of the health home to all patients and in all geographic areas. Currently, the health home is merely a concept and does not practices are stretch goals, but felt that it was appropriate at
                                                    exist widely in practice. As a result, establishing practices as NVCS that are dependent on what is merely a concept is not actionable/implementable for providers. So, in this time to advance the state of the field. The committee felt
                                                    the absence of widely available health homes, the report should clearly convey that providers should be expected to adopt preferred practices 6-25.                         that organizations will implement the practices in a manner that
                                                                                                                                                                                                                                best fits their needs and resources.

Member       Geraldine Bednash, AACN      General    Throughout the report, the performance measurement recommendations supporting the preferred practices are inconsistent with the very principles established by NQF              No action taken. The commentor did not mention the fourth
                                                    – i.e., measures that address outcomes, composites, and focus on disparities. This inconsistency should be addressed either by recommending measures that address                strategic direction , "drive toward high performance." Given the
                                                    these high priorities or excluding any recommended measures that fails to address these priorities.                                                                              current state of measures development, the performance
                                                                                                                                                                                                                                     measures recommended in this report are focused on that,
                                                                                                                                                                                                                                     while we recognize that outcome measures, composites and
                                                                                                                                                                                                                                     disparities are important, they are not available at this time.
                                                                                                                                                                                                                                     NQF is however currently working toward other projects to
                                                                                                                                                                                                                                     address outcome and composite measures.

Non-Member   Jan DeRoche, American        General   Domain: Transitions, The Problem, line 1076 - We recommend modifying language as follows. In particular, the key components for implementations are: a transition                No action taken. The report refers to priniciples adopted by
             Case Management                        record: to include reconciled medication list, date and time of follow up appointment with primary care physician or specialist within 7 days of discharge from acute            other organizations, not NQF. In addition, the commentor
             Association                            setting and follow-up contact with patient or caregiver within 48hrs of discharge. The transitions record is developed by the RN/SW case manager in collaboration with           offers no evidence to support modification
                                                    the healthcare team and the patient/caregiver. The RN/SW case manager completes the 48 hr f/u call or transitions that responsibility to the medical home.

Non-Member   Jan DeRoche, American        General   NQF-endorsed Safe Practices Related to Care Coordination , Safe Practice 12: Patient Care Information, line 1397 - We recommend modifying language as follows, a                 Comment passed to the Safe Practices team for further
             Case Management                        discharge summary prepared by the attending physician. An RN/SW case manager, in collaboration with the patient/caregiver develops a concise transition plan that                information
             Association                            includes key elements of the physicians discharge summary."
Non-Member   Jan DeRoche, American        General   Areas for Future Research, Practices Recommended for Future Research, line 1445 - Add - Effectiveness of certified case managers delivering transitions of care                  Committee recognizes the importance of all team members in
             Case Management                        services.                                                                                                                                                                        the role of care coordination and doesn't need to emphasize
             Association                                                                                                                                                                                                             one specific sector

                                                                                                                  NQF DRAFT: DO NOT CITE, QUOTE, REPRODUCE, OR CIRCULATE                                                                                                                                2
Member       Barbara Rudolph, The         General   The Leapfrog Group supports the National Quality Forum's efforts to address the lack of care coordination evident in our current healthcare delivery environment. The      Comment for which no action can be taken. NQF recognizes
             Leapfrog Group                         Leapfrog Group also supports the effort to develop a comprehensive framework for care coordination measurement. However, the devil is in the details, in particular, the the importance of outcome measures and other NQF projects
                                                    use of terminology that is limiting in terms of application of these metrics. We hope that the National Quality Forum would broaden these preferred practices to all       are currently addressing this issue
                                                    licensed healthcare providers who are delivering "primary care" to patients. In addition, we hope that NQF will quickly address the need for linkage of these practices to
                                                    the outcomes of care. We would like NQF to avoid the same journey through process measures that has occurred with hospital and physician measures.


Non-Member   Jan DeRoche, American        General   Performance Measures for Measuring and Reporting Care Coordination Quality, Evaluating Care Coordination Performance Measures, pg. 57 - We recommend                      No action taken. Commentor is referring to the committee's
             Case Management                        refining the statement. All patients need some aspects of care coordination with the following language. Assure coordinated transition from hospital to community setting screening criteria for the measures
             Association                            by clearly defining the roles and responsibilities of the hospital and community / home- based case manager.


Member       Janet Leiker, American    General      The American Academy of Family Physicians (AAFP) appreciates the work of the Care Coordination Steering Committee. Regarding the controversy over the use and                      Report was reviewed to assess whether the terms were clearly
             Academy of Family                      misleading use of "healthcare home" as opposed to "medical home", the AAFP strongly supports the term "medical home". There is a lack of evidence base for                         delineated; medical home was only used when others used it to
             Physicians. Commission on              coordination of care efforts outside of physician led medical homes.                                                                                                               describe their work. The language stating that the report
             Quality and Practice                                                                                                                                                                                                      utilizes the terms interchangeably was modifed to clarify that
                                                                                                                                                                                                                                       NQF uses the broader term healthcare home, but relied on the
                                                                                                                                                                                                                                       evidence from medical home at this time until additional
                                                                                                                                                                                                                                       implementation and research can be conducted.


Member       Jayne Chambers,              General   The Federation of American Hospitals is pleased to have the opportunity to comment on the review for Endorsing Preferred Practices and Performance Measures for          No action taken. Several of the measures recommended for
             Federation of American                 Measuring and Reporting Care coordination: a Consensus Report. There is no doubt that better care coordination will lead to better patient care, improved quality and    endorsement are time-limited to allow for testing
             Hospitals                              ultimately to reduced cost. New tools in the area of care coordination should be well-tested and focused with specific actions well-defined. The FAH would propose that
                                                    the performance measures be recommended for time-limited endorsement so that field testing can occur. Since care coordination is a relatively new area of
                                                    measurement, we believe that robust testing would provide important information for hospitals and other providers who will be implementing the measures. We recognize
                                                    that the preferred practices are starting with where we are now in the state of care delivery, and we hope we can move forward quickly in further refining practices and
                                                    measures to acheive consistent care coordination.

Member       Jayne Chambers,              General   While we recognize that a great deal of work is represented in the report, we have reservations about a number of the preferred practices which appear to be lacking in            No action taken. The implementation examples are to provide
             Federation of American                 specific implementation plans.                                                                                                                                                     real-world examples of thoes who may be implementing the
             Hospitals                                                                                                                                                                                                                 practice


Member       Jayne Chambers,              General   The FAH would like to see more specific details for measuring real outcomes and accountability across providers.                                                                   No action taken. The commentor does not provide more
             Federation of American                                                                                                                                                                                                    specificity for detail on the measures and a specific measure
             Hospitals                                                                                                                                                                                                                 was not noted, therefore comment cannot be addressing
                                                                                                                                                                                                                                       accurately.

Member       Jill Epstein, American       General   No measures specific to the measurement of quality in the long-term care area are offered, although several general measures can be applied to this arena. quality in     No action taken. NQF will consider these comments on furture
             Medical Directors                      care transitions would be improved if the hospitalist (or designee) was expected to remain available for questions/concerns when a patient is transferred to the LTCC     work addressing care coordination and care transitions
             Association                            until care assumed by a practitioner at the new site of care. A great deal of focus is on the medical home idea. While AMDA sees much to offer in this concept, this is
                                                    essentially irrelevant in the LTCC. What about those without a medical home? P. 57, line 1506 refers to timing of office visits. In the LTCC, visits are predominantly in
                                                    the facility. AMDA would like to ask NQF to emphasize the importance of obtaining advance directives and their importance in planning care coordination and care
                                                    transitions as a method of improving quality. Unnecessary transfers could be eliminated and appropriate sites of care could more readily be identified. AMDA would like
                                                    to ask NQF to emphasize the importance of looking for cognitive issues in transferring patients and their importance in planning are coordination and care transitions as
                                                    a method of improving quality. AMDA encourages more emphasis on the need to early on determine who or what the care giving entity will be for each patient and
                                                    involving them in the hospital//LTCC course. This will ease the transition to the next site of care.


Member       Jill Epstein, American       General   P. 52, line 1378: Rates of adverse events elated to poor transitions of care as an opportunity for measurement; appears very subjective. P.53, beginning line 1395:                No action taken
             Medical Directors                      AMDA would emphasize a summary of care of the hospital stay; athis differs from the discharge summary which is often not available upon our assumption of care,
             Association                            and often lacks key information to continue the plan of care


Member       Jill Epstein, Society of     General   CC-073-09 through CC-076-09 are sound measures and SHM supports them in their current form. Unlike well established process measures, such as those for heart                      Comment supports draft report
             Hospital Medicine                      failure or surgery, the healthcare system is substantially under-resourced to consistently deliver these 4 measures. Thus, the promulgation of these measures must be
                                                    accompanied by meaningful resource allocation with proper incentives/rewards for health organizations (while this is not the job of NQF, it is especially pivotal to the
                                                    relevance of care coordination measures).

Member       Jodie Mitchell, American     General   The American Optometric Association supports the National Voluntary Consensus Standards for Measuring and Reporting Care Coordination. As primary eye care                         No action taken. The healthcare team is intended to include all
             Optometric Association                 providers, optometrists should be included in the medical/health home team.                                                                                                        care providers specific to the patients needs




Member       John Agos, sanofi-adventis   General   NQF has identified important measures for Care Coordination, however, given the current gap in care, it will be a major undertaking for hospitals to provide the transition No action taken. NQF and the Committee recognize this as a
                                                    of care education and documentation and the discharge summary to all inpatients. It will be easier to produce timely discharge summaries than it will to get condition-       first step in addressing measures for care coordination
                                                    specific education for patients for the 20 conditions that Medicare considers responsible for 95% of hospitalizations and to ensure that the receiving team has sufficient
                                                    information and works with it when they see the patient, or initiates contact to follow-up with the patient after they return home. It would be more practical and consistent
                                                    with the step-wise quality improvement process to focus the improvement process for discharge preparation on specific high priority conditions. Diabetes is a high
                                                    priority medical condition, a leading issue with NQF, IOM, Medicare, AMA PCPI, AHRQ, health plans, practicing physicians, patients, employees, employers, and health
                                                    plans. Operationally sound coordination of care is critical to improved care and the outcome for patients with diabetes. We believe it is important for the patient with
                                                    diabetes to have a central place for care, a medical home; a critical missing piece is development and use of a Proactive Plan of Care (PPOC) for all comorbid
                                                    conditions. This is a living document that follows the patient to the ED and into the hospital and back to the clinic setting.


Member       John Agos, sanofi-adventis   General   It is critical to emphasize that the current proposed measures focus only on the discharge summary and discharge information. This is only a small piece of what is                No action taken. NQF and the Committee recognize this as a
                                                    needed to improve patient care and reduce unfavorable outcomes like hospitalization, readmissions, ED visits, adverse events, even amputations. These outcomes                     first step in addressing measures for care coordination.
                                                    reflect a progression of the patients condition, a failure of medication and need to reassess medications or a failure of the medical home system to address the patients          Comment referred to measure developers for informational
                                                    needs in a timely fashion. Better hand-off of information at the time of discharge is expected to have a significant impact on reducing readmissions and preventing costs.         purposes.
                                                    It is important to identify patients at risk before the first hospitalization. (Linden 2008) Only 6.4% of patients hospitalized in a current year were hospitalized in the prior
                                                    year. Waiting to identify patients as high risk until they are hospitalized is not an effective way to predict high cost patients. Patients need to be identified in the
                                                    ambulatory setting and guided care be provided, increased attention to self-management and support strategies like periodic A1c levels as well as frequent contact to
                                                    manage acute changes in condition in order to avoid ED visits and the first hospitalization.


Member       John Agos, sanofi-adventis   General   There are key pieces of care coordination that are not addressed by the measures recommended and those not recommended. The most obvious are 1) measure that                       No action taken. NQF and the Committee recognize this is a
                                                    looks at the care in the medical home, e.g., the development of a PPOC 2) hand-off from the medical home to the hospital at the time of admission (or ED visit).                   first step and that additional measure development will be
                                                    Electronic records may help solve some of the problem but the critical issue is not that records are available. The input of the other sites of care as part of the overall        necessary. With respect to the specificity of the comment re:
                                                    care for each patient must be valued and sought at times of transition. The Proactive Plan of Care should be a comprehensive plan that is developed with the patient to            diabetes, the Committee did not focus on any single disease
                                                    set the therapeutic goals and the timeframe for achieving them, both short and long-term goals. A major part of successful care of patients with diabetes is the working           (except the cardiac rehab submitted practice 10).
                                                    relationship between the patient and their medical team. It takes about 4 encounters to develop the background that will impact the use of tests, prescribing, referrals and
                                                    management. (Rosenthal 2008)
Member       John Agos, sanofi-adventis   General   Setting the treatment goals for diabetes requires an on-going relationship that allows the negotiation to set specific goals for glycemic control and the tentative timetable Comment for which no action can be taken
                                                    for each individual patient. The ACE algorithm for control of Hgb A1c < 6.5% with treatment adjustment every 2-3 months until the goal is reached is a beginning. The
                                                    physician and the patient need to individualize the goal based on the other patient factors, discuss the medication options, including insulin. Progress to meeting the goal
                                                    needs to be monitored and the goal modified as needed. The discussion will probably include a discussion of insulin, Patient concerns and fears and realistic
                                                    expectations need to be addressed. The information should become part of the patients Proactive Plan of Care (PPOC) and then it needs to be communicated to the
                                                    hospital team at the time of admission to allow for transition of care. The PPOC should serve as a template to guide the care in the hospital and inform them of key
                                                    information the patients glycemic target, their preferences for medication, medication tried, and other critical patient issues, including decision-making.


Member       John Agos, sanofi-adventis   General   We support this measure but suggest it is missing specific information about patient education that should be specified in the measure for all patients but especially             Developer Response: Additional required elements were
                                                    patients with diabetes, especially those newly diagnosed, those for whom treatment was changed during the hospital stay and for patients with hyperglycemia under new              considered for the transition record, but the [PCPI] work group
                                                    treatment at the time of discharge. If the patient will be discharged with insulin as a new medication, the education and hand-off of information to the receiving team takes      did not wish to create an excessive documentation burden.
                                                    on added importance because of the issues with appropriate use and patient support. At the very least, the patient with diabetes needs specific instructions in the                Patient understanding of discharge instuctions is the focus of
                                                    appropriate format for the patient (written, pictorial or DVD documentation) on how to recognize high and low blood sugar, how to self-manage, triggers to contact their           other ongoing efforts, including recent enhancements to the
                                                    provider or present to the ED, what to do about missed meals, doses and continued illness and specific instructions related to the acute hospital stay (e.g. wound                 HCAHPS survey, and may be the subject of future measures
                                                    healing, infection). The medication lists and transition of care instructions should contain very specific information for the receiving team to inform them of the patient        development efforts.
                                                    education that was done in the hospital and guide them on where reinforcement or re-evaluation is recommended.

Member       John Agos, sanofi-adventis   General   NQF has identified important measures for Care Coordination; however, it will be a major undertaking for hospitals to address this for all patients. It would be more              No action taken. NQF and the Committee recognize this as a
                                                    practical and increase the chance for success if they focused attention on the conditions and patients most at risk for problems at the time of discharge or before. Atrial        first step in addressing measures for care coordination. In
                                                    fibrillation (AF) is one of the 20 conditions identified by Medicare for increased attention. a condition which would benefit from concerted coordination of care in all           addition, TIA patients have a high mortality risk, up to 25
                                                    treatment settings. It is an intermittent condition whose treatment is associated with repeat hospitalization for management. As a chronic condition, it is the most               percent will die within one year of a TIA. As such, this is a high
                                                    common chronic cardiac arrhythmia in practice. (AHRQ Report 2009) The AHRQ reports notes that the heavy burden of AF creates a pressing need for novel                             priority condition.
                                                    approaches to management. (AHRQ, Background.) Disease management data suggests that it is more effective to reduce hospitalizations if the at-risk patient is
                                                    identified before the first hospitalization and guided care is implemented, e.g. self-management and support strategies, to avoid the first hospitalization. This applies to
                                                    AF. In addition to hospitalizations for AF as the primary diagnosis, it is associated with even more admissions as a secondary diagnosis and increases the morbidity
                                                    and mortality for these conditions, e.g. CHF, Stroke, CV death and all-cause mortality.


Member       Laura Blum, The Heart        General   As a National Quality Forum member, the Heart Rhythm Society is pleased to provide written comments on the draft report, National Voluntary Consensus Standards                    Comment for which no action can be taken
             Rhythm Society                         for Measuring and Reporting Care Coordination. The Heart Rhythm Society is the international leader in science, education and advocacy for cardiac arrhythmia
                                                    professionals and patients, and the primary information source for heart rhythm disorders. Founded in 1979, the Heart Rhythm Society is the preeminent professional
                                                    group representing more than 5,000 specialists in cardiac pacing and electrophysiology, consisting of physicians, scientists and their support personnel.


Non-Member   Lauren Agoratus, Family      General   Thank you for the opportunity to comment on the proposed document ―Endorsing Preferred Practices and Performance Measures for Measuring and Reporting Care           No action necessary
             Voices                                 Coordination: A Consensus Report.‖ Family Voices is a national network that advocates on behalf of children with special healthcare needs and their families. Our NJ
                                                    Chapter is housed at the Statewide Parent Advocacy Network (SPAN), NJ’s federally funded Parent Training and Information Center which is also NJ’s Family-to-Family
                                                    Health Information Center and a chapter of the Federation of Families for Children’s Mental Health. The Family Voices Coordinator also serves as the NJ Caregiver
                                                    Community Action Network representative for National Family Caregivers Association in a volunteer capacity. Our comments are as follows:


Non-Member   Lauren Agoratus, Family      General    In general, we support the NQF framework for care coordination in the areas of the medical home, care plan, communication, information systems, and transitions to        No action necessary
             Voices                                 care. We agree that care coordination will improve care and increase quality, improve communication including patient input, and reduce hospitalization. We support
                                                    NQF’s mission to set national priorities/goals to improve performance, national consensus standards for measurement including public reporting, and education/outreach
                                                    programs. We agree with the strategy direction of NQF in the development of these standards particularly as it relates to measuring outcomes, including health
                                                    disparities. We support the project’s goal of endorsing 25 preferred practices (that address the NQF framework) and research on evaluation of care coordination. We
                                                    agree that the evaluation criteria of best practices need to have evidence of effectiveness, generalizability across clinical settings, benefit by improving outcomes, and
                                                    there must be staff readiness in terms of skill level and needed technology.

Non-Member   Lauren Agoratus, Family      General   In Table 2, we agree with the recommended national standards for care coordination such as cardiac, cancer, etc. but would like to see additional disease-specific                 No action necessary
             Voices                                 information such kidney disease, gastrointestinal, audiologic, etc. Thank you for the opportunity to comment on the NQF proposed guidelines on care coordination and
                                                    practice measures

Non-Member   Lauren Agoratus, Family      General   In Appendix A-Specifications of the National Voluntary Consensus Standards for Care Coordination‖, under the ―reconciled medication‖ area we were pleased to see not Comment supported current draft, no action necessary
             Voices                                 just adverse events and allergies, but consideration given to ―prescription, over-the-counter, and herbal products‖. The NIH (National Institutes of Health) has recognized
                                                    the importance of alternative medicine and has established to National Center for Complementary and Alternative Medicine to study this.


Non-Member   Lauren Agoratus, Family      General   Additionally, under the ―transition record‖ area, we were pleased to see the realization of the importance of advanced directives.                                                 Comment supported current draft, no action necessary
             Voices
Non-Member   Lauren Agoratus, Family      General   Also under ―transition record-discharge‖, we support the measurement of patients/caregivers who have a record ―at the time of emergency department discharge‖ as                   Comment supported current draft, no action necessary
             Voices                                 families in crisis may not remember care recommendations if they are only given verbally.

Non-Member   Lauren Agoratus, Family      General   Under the ―care transition measure‖ we were pleased to see this was able to be used with patients who have cognitive disabilities as well as English language learners.            Comment supported current draft, no action necessary
             Voices
Member       Lee Anne Gardner,            General   The ACP Performance Measurement Subcommittee is concerned that the practices are evaluated by the evidence of effectiveness, generalizability, benefit and                         Comment for which no action can be taken in this report.
             American College of                    readiness (page 8 of the main document). There seems to be no process to evaluate and grade the evidence in such a way to inform stakeholders about the strength of                However, NQF is convening a task force to review evidence
             Physicians, Performance                evidence used to support these practices.                                                                                                                                          and grading for measures and practices.
             Measurement
             Subcommittee
Non-Member   Margaret Chu, Winthrop       General   I found the documents and process for evaluating the care coordination standards extremely unclear and confusing.                                                                  Comment for which no action can be taken
             University Hospital

Non-Member   Margaret Chu, Winthrop       General   The 25 standards (practices) do not have direct pertinence to care coordination.                                                                                                   Disagree. No action necessary
             University Hospital




                                                                                                                  NQF DRAFT: DO NOT CITE, QUOTE, REPRODUCE, OR CIRCULATE                                                                                                                                    3
Member       Barbara Rudolph, The         General   The Leapfrog Group supports the National Quality Forum's efforts to address the lack of care coordination evident in our current healthcare delivery environment. The      Comment for which no action can be taken. NQF recognizes
             Leapfrog Group                         Leapfrog Group also supports the effort to develop a comprehensive framework for care coordination measurement. However, the devil is in the details, in particular, the the importance of outcome measures and other NQF projects
                                                    use of terminology that is limiting in terms of application of these metrics. We hope that the National Quality Forum would broaden these preferred practices to all       are currently addressing this issue
                                                    licensed healthcare providers who are delivering "primary care" to patients. In addition, we hope that NQF will quickly address the need for linkage of these practices to
                                                    the outcomes of care. We would like NQF to avoid the same journey through process measures that has occurred with hospital and physician measures.


Non-Member   Margaret Chu, Winthrop       General   The standards (measures) listed are more HEDIS-like clinical measures rather than measuring direct care coordination.                                                               Comment for which no action can be taken
             University Hospital

Member       Mary Andrawis, American      General   COMMENTS ON PROPOSED BUNDLING OF MEASURES CC-074-09, CC-075-09, AND CC-076-09. The Society applauds the reporting of separate performance                                           Comment supports draft report
             Society of Health-System               scores for these three measures independently as well as reporting as a bundle. This will measure success for individual measures that provide benefit even if
             Pharmacists                            implemented alone. Because these measures have not yet undergone pilot studies, there is no data that shows, when done together, a greater improvement to patient
                                                    outcomes than when each is done independently. Independent measurement will allow for assessment of the validity of each measure and whether weighting should be
                                                    applied to the bundled measure.


Member       Mary Andrawis, American      General   NQF-ENDORSED SAFE PRACTICES RELATED TO CARE COORDINATION ASHP strongly recommends inclusion of Safe Practice 18: Pharmacist Leadership                                    Safe Practice 18 will be referenced accordingly within the care
             Society of Health-System               Structures and Systems on line 1389 as a safe practice related to care coordination. This safe practice has a direct and significant impact on care coordination as an    coordination report
             Pharmacists                            estimated 60 percent of medication errors occur during times of transitions and often result in preventable and costly hospital readmissions.1 Suggested text from the
                                                    safe practice is as follows: Pharmacists should work with the interdisciplinary team to ensure safe and effective medication use across the continuum of care as patients
                                                    move from one setting to another (e.g., from ambulatory care to inpatient to home care).

Member       Mary Andrawis, American      General   On behalf of the American Society of Health-System Pharmacists (ASHP), thank you for the opportunity to review and comment on the draft document Endorsing                          Comment for which no action can be taken
             Society of Health-System               Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination: A Consensus Report. For more than 60 years, ASHP has helped
             Pharmacists                            pharmacists who practice in hospitals and health systems improve medication use and enhance patient safety. The Societys 35,000 members include pharmacists and
                                                    pharmacy technicians who practice in inpatient, outpatient, home-care, and long-term-care settings.

Member       Mary Naylor, University of   General   The term ―medical home‖ is limited in the use of physicians as providers of coordinated, primary care whereas the term ―health home‖ is inclusive of all primary care         Review report to clearly delineate the use of both terms. the
             Pennsylvania School of                 practitioners. Additionally, the two terms are not interchangeable despite the report’s suggestion that they are (lines 217-219). So, for consistency, the term ―health home‖ report utilizes the terms interchangeably relying on the evidence
             Nursing                                – a widely accepted term -- should be used throughout the report.                                                                                                             used to support the medical home at this time. further
                                                                                                                                                                                                                                  clarification was added to report.


Member       Mary Naylor, University of   General   Throughout the document primary care is limited used to physician care (e.g., primary care physician) and fails to acknowledge that nurse practitioners often serve in              The use of primary care physician is confined to
             Pennsylvania School of                 primary care roles. Alternatively, the term ―primary care practitioners‖ or ―primary care providers‖ should be used throughout the report.                                          implementation examples or references in which it was clear
             Nursing                                                                                                                                                                                                                    that a physician was needed. When it was within our control we
                                                                                                                                                                                                                                        used the more generic of those terms except for a few
                                                                                                                                                                                                                                        physician-focused practices, which the Committee needs to
                                                                                                                                                                                                                                        revisit.
Member       Mary Naylor, University of   General   The terminology ―plan of care‖ is used throughout the report yet never defined. In some cases this term appears to refer to medical services only; in others it applies to a No action taken. The specifications of practice 6 articulate the
             Pennsylvania School of                 broader definition that includes community and non-clinical services. A clear definition of plan of care including its essential components should be established in this    essential compenents of the plan of care
             Nursing                                report.



Member       Mary Naylor, University of   General   Practices 1-5 are dependent on the availability of the health home to all patients and in all geographic areas. Currently, the health home is merely a concept and does not No action taken. The committee recogized that some practices
             Pennsylvania School of                 exist widely in practice. As a result, establishing practices as NVCS that are dependent on what is merely a concept is not actionable/implementable for providers. So, in are stretchable but felt that it was appropriate at this time to
             Nursing                                the absence of widely available health homes, the report should clearly convey that providers should be expected to adopt preferred practices 6-25.                         advance the state of the field. The committee felt that
                                                                                                                                                                                                                                organizations will implement the practices in a manner that best
                                                                                                                                                                                                                                fits their needs and resources.

Member       Mary Naylor, University of   General   Throughout the report, the performance measurement recommendations supporting the preferred practices are inconsistent with the very principles established by NQF                  No action taken. The commentor did not mention the fourth
             Pennsylvania School of                 – i.e., measures that address outcomes, composites, and focus on disparities. This inconsistency should be addressed either by recommending measures that address                   strategic direction drive toward hihg performance. Given the
             Nursing                                these high priorities or excluding any recommended measures that fails to address these priorities                                                                                  current state of measures development, the performance
                                                                                                                                                                                                                                        measures recommended in this report are focused on that,
                                                                                                                                                                                                                                        while we recognize that outcome measures, composites and
                                                                                                                                                                                                                                        disparities are important, they are not available at this time.
                                                                                                                                                                                                                                        NQF is however currently working toward other projects to
                                                                                                                                                                                                                                        address outcome and composite measures.

Member       Mary Naylor, University of   General   • Page 13, Line 211 -- As stated, this suggests that the health home has been proven (e.g., tested) which is not the case. Delete the term ―proven‖                                 Comment incorporated into report
             Pennsylvania School of
             Nursing


Member       Mary Naylor, University of   General   Page 14, Line 235 -- The sentence starts with ―other models‖ but then simply reverts to content related to the medical home. Delete ―other models such as‖                          Comment incorporated into draft report
             Pennsylvania School of
             Nursing


Member       Mary Naylor, University of   General   Page 20, Line 407 --―balance measures for quality outcomes‖ is not clear. Clarify this statement.                                                                                   Further clarification was provided in report. The statemment
             Pennsylvania School of                                                                                                                                                                                                     was referring to measures focused on outcomes
             Nursing

Member       Mary Naylor, University of   General   Page 41, Line 1044-1045 -- ―…who is admitted to the hospital will experience a transition…‖While this is true, what is more accurate is that ―…who receive inpatient care           No action taken
             Pennsylvania School of                 of any type will experience a transition…‖
             Nursing

Member       Mary Naylor, University of   General   Page 41, Line 1052 -- These health care professionals should be accountable for transitional care services. Please modify to read: ―…the availability of healthcare                 Comment incorporated into draft report
             Pennsylvania School of                 professionals who are accountable for transitions and who are well trained….‖
             Nursing

Member       Mary Naylor, University of   General   Page 42, Line 1056 -- It is not just physicians who work in silos. Modify to read: ―…are evident, health care practitioners often work in silos…‖                                   Comment incorporated into draft report
             Pennsylvania School of
             Nursing

Member       Michelle Beauchesne,         General   The National Association of Pediatric Nurse Practitioners (NAPNAP), along with the American Academy of Pediatrics (AAP), are pleased to have the opportunity to       Comment for which no action can be taken
             National Association of                comment on the National Quality Forums (NQF) preferred practices and performance measures for care coordination. NAPNAP is pleased to join with the AAP in our
             Pediatric Nurse                        comments. We have worked with the AAP on multiple programs throughout many years promoting health for our pediatric population; we contributed expertise to many
             Practitioners (NAPNAP)                 AAP programs and projects including the renowned Bright Futures program, supported multiple grants, and currently serve as a member of the AAP Medical Home
                                                    Project Advisory Committee (PAC). As a member of the AAP Medical Home PAC, NAPNAP collaborated and contributed to these proffered comments. NAPNAPs
                                                    7,000 members applaud the NQFs efforts to improve Americas healthcare through the endorsement of consensus-based national practices and measures to assess the
                                                    quality of the nations healthcare. The document is thorough, organized, and carefully considered vis a vis prioritizing under the Quality Management concept "ABNA"
                                                    (Achievable Benefits Not Achieved). While NAPNAP along with the AAP commend the NQF on its efforts, we also use this opportunity to offer the following
                                                    observations and suggestions to improve the proposed practices and measures. We also include sample implementation efforts that reflect specific preferred practices.



Member       Michelle Beauchesne,         General   NAPNAP along with the AAP are very concerned that the proposed practices and measures for care coordination do not address adequately all patient populations. The Throughout the report, the reference is made to patients, which
             National Association of                standards are heavily geared towards mentally competent, ambulatory, adult patients. In fact, the documents definition of the healthcare home fails to include patient- and includes child/youth and is not limited. The report was reviewed
             Pediatric Nurse                        family-centered qualities that are vital in pediatrics, geriatrics, as well as for individuals unable to advocate and/or care for themselves. NAPNAP along with the AAP     inclusion of cultural and linguistic effectiveness and added when
             Practitioners (NAPNAP)                 strongly urge the NQF to insert the words child/youth/adult and family wherever possible, along with reference to cultural and linguistic effectiveness.                    appropriate.

Member       Michelle Beauchesne,         General   Additionally, the NQF document defines transitions in care as events across healthcare settings, particularly those associated with or following hospitalizations. The          NQF defines transitions according to the NQF endorsed
             National Association of                definition of transitions should be broadened to include other transfers of care, such as life transitions from one clinician or care setting to another. One of the most       Framework for care coordination. Consideration of revising this
             Pediatric Nurse                        important life transitions is from adolescence to adulthood, or from the pediatric model of care that includes parents as surrogate decision-makers to a more                   definition will be made as the framework is updated
             Practitioners (NAPNAP)                 independent adult care model. This often involves a change in the patients medical home and primary provider. For youth with special health care needs, this transition
                                                    also may involve a transfer of care from pediatric to adult specialists. While life transitions may lack the acuity of risk associated with hospital discharge transitions, the
                                                    risk for disruption of continuity and quality of care is no less of a concern. During these transitions, information can get lost, patient and clinician intentions become
                                                    ambiguous, and planning is absent, delayed, or undocumented. Special consideration also should be given to small and/or rural practices, which often face limitations
                                                    such as the means to implement electronic health records (EHRs) and to access follow-up and specialty services (eg, physical therapist in the next major city which could
                                                    be hours away). Following are comments in the following domains: Healthcare Home, Proactive Plan of Care and Follow Up, Communication, Information Technology,
                                                    Transitions, and Performance Measures.

Member       Nancy Foster, American       General   (AHA 1 of 3) The American Hospital Association (AHA) is pleased to review the care coordination draft preferred practices and performance measures. In general, we                  Comment supports draft report
             Hospital Association                   believe that the preferred practices selected by the National Quality Forum (NQF) represent actions that providers can take to ensure the best care possible for their
                                                    patients and fit well within the NQF's previously defined framework for care coordination. The preferred practices, and some of the performance measures, are
                                                    purposefully applicable and generalizable to multiple care settings, populations and providers. This generalizability is critical for care coordination, as multiple providers
                                                    often are involved in a patient's care, particularly when a patient transitions from one care setting to another.

Member       Nancy Foster, American       General   (AHA 2 of 3) However, the involvement of multiple providers also creates challenges when trying to assess the quality of the care provided. To assess providers' quality, Comment for which no action can be taken within report, but will
             Hospital Association                   accountability must be assigned to different providers for each component of a patients care. Thus far, determining how to assign this accountability has challenged      be reviewed in context of NPP and other NQF work
                                                    quality improvement experts as well as policymakers. In identifying the preferred practices and performance measures for care coordination, the NQF has the
                                                    opportunity to provide direction on how to implement these practices and measures by providing a framework for how to assign this accountability among various
                                                    providers. Unfortunately, this discussion is absent from the draft report. We believe it will be challenging to move forward with the practices and measures without some
                                                    guidance or suggestions for implementing them. We suggest that the NQF continue its care coordination work to by developing such an implementation framework.


Member       Nancy Foster, American       General   (AHA 3 of 3) Several of the preferred practices focus specifically on transitions from one setting of care, typically a hospital, to another setting, usually the patient's Comment incorporated into report.
             Hospital Association                   home or a post-acute care setting. In suggesting opportunities for measurement for these practices, the NQF lists hospital readmissions as a potential measure for
                                                    many of them. While hospital readmission rates may be an important component to measure, they alone will create an incomplete picture of the care provided. There are
                                                    many processes and intermediate outcomes that should be assessed to determine how well the practices are being followed, in addition to the endpoint of a hospital
                                                    readmission. For example, for preferred practice #19, "engaging patients and their designees to determine and prepare for ongoing care during and after transitions,"
                                                    measures to assess the quality of the patient education materials, the skills of the self-management coach, and whether or not the patient was able to absorb and retain
                                                    the information received are all important assessment tools to determine the success of the preparation process. We suggest that the NQF expand the list of
                                                    measurement opportunities for these practices to include more of these intermediate processes and outcomes. By listing them in the report, measure developers may
                                                    be encouraged to create these measures and add to the body of care coordination assessment tools.


Member       Nancy Nielsen, AMA           General   The American Medical Association (AMA) appreciates the opportunity to comment on the National Quality Forum’s (NQF) Endorsing Preferred Practices and                               The link was inadvertently ommitted. Links to the code sets will
                                                    Performance Measures for Measuring and Reporting Care Coordination report. While we support this report and its goals of improving care coordination, we would like                 be provided if available, but not all measures center around
                                                    to express a broader concern with a trend in this report and others in which measures appear to lack full specifications (eg, ICD-9 CM, CPT®). The inclusion of the                 ICD-9 CM or CPT. Measure developers will be asked to
                                                    applicable specifications and coding allows for consistent implementation across providers as well as transparency in measure definitions. Lack of specificity inhibits the         review this comment and, as applicable, ensure the
                                                    use of performance measures as a source to guide consistent and appropriate care. We encourage the NQF to reiterate the importance of including specifications for all              specifications are complete, and if applicable, ICD-9 CM or
                                                    measures when measures are evaluated. We appreciate the opportunity to comment.                                                                                                     CPT codes supplied
Member       Pat Ford-Roegner,            General   The suggestion that a physician-led medical home marks a sharp departure from the inclusive, patient-centered approach the National Quality Forum has maintained to                 The practices overall focus on teams, although a few that the
             American Academy of                    date. In its 2006 "NQF-Endorsed™ Definition and Framework for Measuring Care Coordination," NQF places ensuring a patient’s needs and preferences at the center                     Committee must discuss are physician-specific. In fact,
             Nursing                                of its very own definition of care coordination, including a patient’s choice of provider; the current report is inconsistent with that principle and suggests that physician-led   Practice 1 specifically makes the patient the center by
                                                    medical homes are a best practice supported by evidence. This suggestion fails to account for the variety of other practitioners providing primary care, including nurse            emphasizing he/she shall have the opportunity to select the
                                                    practitioners, and is not supported by evidence beyond ―experiential data.‖ This assertion is equally inconsistent with the NQF-convened National Priorities Partnership            provider that best meets his/her needs. This is entirely
                                                    report and its inclusive and uniform use of ―healthcare professionals,‖ its citation of Columbia University’s broad definition of a primary care provider, and its reference        consistent with the NQF Framework.
                                                    to nurse-led examples of care coordination throughout.

Member       Pat Ford-Roegner,            General   The NQF lists its first evaluation criterion as ―effectiveness‖ which demands that ―clear evidence…[indicating] that the practice would be effective in improving outcomes‖         The report centers on the healthcare home, which is not
             American Academy of                    be presented. The report, however, admits that the quality of the evidence used to support the recommended practices varies greatly. In that NQF’s vision is to be a                denoted by NQF as being physician led. The report was
             Nursing                                driving force of quality improvement, AAN encourages NQF to revisit its recommendation of a medical home in the absence of any supporting evidence. There is no                     clarified to indicate that the evidence used to support the
                                                    hard data to indicate that a physician-led medical home is an effective approach to care coordination; indeed, the report states that ―the majority of practices were               practices was from the medical home literature. Additional
                                                    recommended on their face validity.‖ The Steering Committee has failed to consider the hundreds of nurse-managed health centers (NMHCs) across the country that                     citations related to nurse-managed health centers will be
                                                    already function as health care homes for many individuals, and which do have clinical outcomes and cost-savings data. Information on these NMHCs and supporting                    reviewed and added, as appropriate.
                                                    data has been submitted with these comments. It should be noted that the Eleventh Street Family Health Services of Drexel University, an NMHC providing primary care,
                                                    is cited in the National Priorities Partnership report, including its outcomes. The Academy encourages the Committee and NQF to further explore alternatives and
                                                    evidence prior to making and endorsing recommendations. The consequences of failure to do so could have long-term and detrimental effects to patients and the
                                                    system as a whole.

Member       Pat Ford-Roegner,            General   As the report underscores, the term ―medical home‖ is limited to the use of physicians as primary providers and was, in fact, defined by physician groups; the term                 Report was reviewed to assess whether the terms were clearly
             American Academy of                    ―healthcare home‖ is inclusive of all primary care practitioners. Thus, the two terms are not interchangeable in spite of the report’s contention and use and, again, stands        delineated; medical home was only used when others used it to
             Nursing                                in stark contrast to the Institute of Medicine’s holistic approaches and terminology endorsed in "Primary Care: America’s Health in a New Era" and "Crossing the Quality            describe their work. The language stating that the report
                                                    Chasm."                                                                                                                                                                             utilizes the terms interchangeably was modifed to clarify that
                                                                                                                                                                                                                                        NQF uses the broader term healthcare home, but relied on the
                                                                                                                                                                                                                                        evidence from medical home at this time until additional
                                                                                                                                                                                                                                        implementation and research can be conducted.




                                                                                                                   NQF DRAFT: DO NOT CITE, QUOTE, REPRODUCE, OR CIRCULATE                                                                                                                                  4
Member       Barbara Rudolph, The        General   The Leapfrog Group supports the National Quality Forum's efforts to address the lack of care coordination evident in our current healthcare delivery environment. The      Comment for which no action can be taken. NQF recognizes
             Leapfrog Group                        Leapfrog Group also supports the effort to develop a comprehensive framework for care coordination measurement. However, the devil is in the details, in particular, the the importance of outcome measures and other NQF projects
                                                   use of terminology that is limiting in terms of application of these metrics. We hope that the National Quality Forum would broaden these preferred practices to all       are currently addressing this issue
                                                   licensed healthcare providers who are delivering "primary care" to patients. In addition, we hope that NQF will quickly address the need for linkage of these practices to
                                                   the outcomes of care. We would like NQF to avoid the same journey through process measures that has occurred with hospital and physician measures.


Member       Pat Ford-Roegner,           General   While the report and NQF maintain that accountability is central to care coordination, the report fails to define ―accountability.‖ Given the broad and potentially significant    No action. Accountability historically has been acknowledged
             American Academy of                   implications—including payment—in holding practitioners accountable, this should be defined prior to the endorsement of a framework.                                               by NQF in the context of public reporting and/or pay-for-
             Nursing                                                                                                                                                                                                                  performance, as distinguished from internal-only quality
                                                                                                                                                                                                                                      improvement. Specific use of practices and measures--and
                                                                                                                                                                                                                                      hence details of the accountable unit--have been left to
                                                                                                                                                                                                                                      implementation.

Member       Pat Ford-Roegner,           General   Similarly, ―plan of care‖ appears to assume different meanings throughout the course of the report, limited to medical services in some instances and to broader                   Practice 6 specifies the core components of plan of care.
             American Academy of                   community services in others. If this framework is to be offered to practices across the country to encourage their implementation of safe, effective, coordinated care,
             Nursing                               ―plan of care‖ should be specified or, alternatively, should be stated to be a decision left to each community and practice depending on the population served.

Member       Phelan Michael, Cleveland   General   Accrding to NQF own criteria there does not appear to be suffciuent evidence that if the practice were imeplented would be effective or would improve patient outcomes. Committee acknowledges that the practices are a starting point
             Clinic                                The idea that this would be easily genralizable or the readiness of many ed to implement some of thses recoendations is questionable.                                   and will be further refined once more evidence is available to
                                                                                                                                                                                                                           support it



Non-Member   Rebecca Perez, Carative     General    RE: Standards for Care Coordination: Very comprehensive and address the important practice methods to improve outcomes and decrease the potential of                              Comment for which no action can be taken
             Health Solutions, LLC                 complications related to poor transitions.


Non-Member   Rebecca Perez, Carative     General   RE: Measures: in general, the measures are not specific enough to be able to evaluate effectiveness. Specifically, Medication Reconciliation lacks detail about the steps No action taken. the committee recognizes that the measures
             Health Solutions, LLC                 to reconcile meds before a transition. From observed current practices, having the patient sign a form that lists their medications is not adequate. Having followed      are a first step for addressing care coordination
                                                   patients after discharge, over 50% are unaware of the names of their meds, their actions, dosage, or side effects. Another example: providing the patient or caregiver
                                                   with the Transition Record is not adequate. Both patient and caregiver should receive education about the content of the record for better understanding and adherence.



Member       Rebecca Zimmermann,         General   AHIP Comments on NQF Care Coordination Preferred Practices and Proposed Measures                                                                                                   Nomment supported current draft, no action necessary
             AHIP
                                                   AHIP appreciates the opportunity to comment on the Care Coordination Preferred Practices and measures. Care coordination is an important provider function that can
                                                   help reduce re-hospitalizations and emergency department visits, increase patient safety, and improve overall patient satisfaction.


Member       Rebecca Zimmermann,         General   ―Patient-centered medical home‖ (PCMH) is the most common nomenclature in literature and practice, AHIP suggests that the report reference both terms in the report.               Report was reviewed to assess whether the terms were clearly
             AHIP                                  There are many on-going activities to test the concept of PCMH/ health care home models, as well as accountable care organization (ACO) models with PCMH                           delineated; medical home was only used when others used it to
                                                   components. Many projects started during the last one to two years and results may not yet be available. It is not clear if NQF is recommending the proposed practices             describe their work. The language stating that the report
                                                   be incorporated into existing projects or new models under development. It would be helpful to better understand if the preferred practices will be influenced by future           utilizes the terms interchangeably was modifed to clarify that
                                                   learning and how NQF intends to maintain or evolve these preferred practices in a rapidly changing environment.                                                                    NQF uses the broader term healthcare home, but relied on the
                                                                                                                                                                                                                                      evidence from medical home at this time until additional
                                                                                                                                                                                                                                      implementation and research can be conducted. As with all
                                                                                                                                                                                                                                      NQF consensus standards, the practices will be updated as
                                                                                                                                                                                                                                      part of maintenance.

Member       Rebecca Zimmermann,         General   The performance measurement recommendations supporting the preferred practices are inconsistent with the principles established by NQF – i.e., measures that        No action taken. The commentor did not mention the fourth
             AHIP                                  address outcomes, composites, and focus on disparities. This inconsistency should be addressed by recommending measures that specifically address these priorities. strategic direction , "drive toward high performance." Given the
                                                   A crosswalk that demonstrates how measures align with the practices would also be helpful in identifying gaps in measurement.                                       current state of measures development, the performance
                                                                                                                                                                                                                       measures recommended in this report are focused on that,
                                                                                                                                                                                                                       while we recognize that outcome measures, composites and
                                                                                                                                                                                                                       disparities are important, they are not available at this time.
                                                                                                                                                                                                                       NQF is however currently working toward other projects to
                                                                                                                                                                                                                       address outcome and composite meausres.



Member       Rebecca Zimmermann,         General   According to a disclaimer in the report (page A-1), detailed specifications with coding are not supplied in the report, but are available through links contained in the report. A detailed lsit of the specifications including the codes for the
             AHIP                                  AHIP recommends that a summary of the detailed specifications be provided in the report as well as the links.                                                                    recommended measures is provided within the report.
                                                                                                                                                                                                                                    Hyperlinks for measure codes are provided when available.



Member       Rebecca Zimmermann,         General   The Cardiac Rehabilitation measures (CC-19-09 & CC-20-09) list several alternative data sources in addition to the NCDR registry, including electronic health records,             A list of pertinent diagnosis and procedure codes for use with
             AHIP                                  electronic claims, and paper medical review. AHIP firmly believes that if a measure can be collected by different data sources, detailed specifications for all data               the CR performance measures will be prepared by the measure
                                                   sources should be provided by measure stewards. Standardized specifications will ensure that measure users will implement the measures consistently.                               developer and the measure codes will be updated accordingly

                                                   If detailed specifications are not provided to measure users, variation in implementation will result in non-comparable data. Each time the measure is implemented, a
                                                   unique measure may be created (measure users would become de facto measure developers) and nationally consistent specifications will not be created.




Non-Member   Renee Demski, Johns         General   Performance Measures: Coordination of care throughout these measures is certainly important, but I think the NQF needs to make sure the measures are within the                    No action taken. The performance measures as specified
             Hopkins Medicine                      control of the hospital if we are going to be held accountable for adhering to them.                                                                                               clearly identify who should be accountable

Non-Member   Renee Demski, Johns         General   Also, these metrics are all still process, and not outcome, measures.                                                                                                              No action taken. NQF currently has a porject underway to
             Hopkins Medicine                                                                                                                                                                                                         address outcomes measures




Non-Member   Renee Demski, Johns         General   There are concerns regarding the ability to capture all the necessary information required to track these metrics. Collecting data and implementing electronic systems to          No action taken. The committee recogizes these measures
             Hopkins Medicine                      enable data collection will be quite labor and time intensive.                                                                                                                     have not been tested and therefore a time-limited endorsement
                                                                                                                                                                                                                                      will allow for that assessment.


Non-Member   Renee Demski, Johns         General   It would be impossible for community hospitals to gather data on many performance measures. Because patients are seen by private community physicians, community Developer Response: No action taken. Measures CC-050-09,
             Hopkins Medicine                      hospitals do not have access to their health records. Examples would be CC-050-09 and CC-071-09 - while the hospital can ascertain that an appointment was made on the data source is claims data, not the hopitals records.
                                                   discharge or that a biopsy result was communicated to the provide, we cannot determine what the patient or provider did after discharge.                           Measure CC-071-09, the commentor says that the hospital can
                                                                                                                                                                                                                      assertain that an appointment was made, but cannot determine
                                                                                                                                                                                                                      what the patient did after discharge. The point of the measure
                                                                                                                                                                                                                      is to communicate results following a biopsy, this should be
                                                                                                                                                                                                                      communicated with the primary care physician and the patient
                                                                                                                                                                                                                      and documented

Non-Member   Renee Demski, Johns         General   Recommended practices: #1: Best compared to what? Most appropriate compared to what?                                                                                               Practice statement was modified to indicate that the best and
             Hopkins Medicine                                                                                                                                                                                                         most appropriate services will be provided to the patient



Non-Member   Renee Demski, Johns         General   Recommended practices: #13: Need more clarification on the definition of care partner                                                                                              The specifications indicate that the care partner should be a
             Hopkins Medicine                                                                                                                                                                                                         family member, friend or volunteer




Non-Member   Renee Demski, Johns         General   Recommended practices: # 14: Great idea, but could be quite onerous and bureaucratic if implemented too rigidly. Could add busy-work to the already stressed day of                No action taken. Committee felt it was important to include this
             Hopkins Medicine                      the provider, and only serves a purpose if it results in changes in care patterns.                                                                                                 element in care coordination. An implementation example is
                                                                                                                                                                                                                                      noted in the report to deomnstrate the feasibility.

Non-Member   Renee Demski, Johns         General   Recommended practices: # 22: Communication templates that are standardized to some extent is a great idea, but individualized documents are going to be needed,                    No action taken. The practice clearly states that a minimum set
             Hopkins Medicine                      and its not clear who generates/receives the communication beside the patient and designee.                                                                                        of core data elements, therefore, there could be more. With
                                                                                                                                                                                                                                      respect to the communcation, a separate practice makes clear
                                                                                                                                                                                                                                      who should receive access to the information

Non-Member   Renee Demski, Johns         General   Health care home definition needs more specificity in its definition. It's not clear who will lead this virtual home of care coordination. The idea is an excellent one in regard No action taken. The language defining the healthcare home
             Hopkins Medicine                      to having one clearinghouse of information and handoff communication and triage.                                                                                                  was previously endorsed.



Non-Member   Renee Demski, Johns         General   The "transitions" work is especially interesting in regards to healthcare reform and quality - reducing cost by reducing redundancy especially in frail elderly.                   Comment for which no action can be taken
             Hopkins Medicine



Non-Member   Renee Demski, Johns         General   The performance measures and best practices are well defined but I don't see anything regarding preventative screening or well care.                                               No action taken. The soecifications for practice 1 indicate that
             Hopkins Medicine                                                                                                                                                                                                         the healthcare home should serve as the main point of contact
                                                                                                                                                                                                                                      for all "comprehensive care services"

Non-Member   Renee Demski, Johns         General   I think there also needs to be specifics regarding the expectation that a date of birth will reveal patients' last healthcare encounter across all settings to ensure expedient,   Intent of comment unclear
             Hopkins Medicine                      safe and cost effective care.
Non-Member   Renee Demski, Johns         General   Also, type of provider coordinating and/or intervening should be readily accessible to enhance provider to provider communication and for auditing quality and diversity           No action taken. Ongoing work in NQF's HIT protfolio would
             Hopkins Medicine                      by provider type.                                                                                                                                                                  appear to address this problem, by identifying the core data
                                                                                                                                                                                                                                      elements needed
Non-Member   Renee Demski, Johns         General   The endorsed CC practices assume a healthcare home organizational structure. While there is much published literature on this, the original outcomes from the CMS                  No action taken. Committee felt recogizes that the practices
             Hopkins Medicine                      demonstration project have yet to be determined. These all seem to be important goals to get to and once processes are established, then perhaps the outcomes can                  are a starting point and will be further refined once more
                                                   be better measured (i.e. Having a standardized electronic patient record will facilitate outcomes related to transitions of care, however these are nowhere near in sight).        evidence is available to support it




Non-Member   Renee Demski, Johns         General   Most if not all of these measures have not yet been tested.                                                                                                                        No action taken. Untested measures are recommended for
             Hopkins Medicine                                                                                                                                                                                                         time-limited endorsement
Non-Member   Renee Demski, Johns         General   In addition all of the transitions of care measures use data abstraction, making them labor intensive and the feasibility low. All in all, most of these (especially related to    No action taken. Commentor makes reference to measure 74,
             Hopkins Medicine                      transitions of care) are important but not nearly ready for prime time or public reporting. The transitions of care measures to me have the most possibilities but again           which is recommended for endorsment on a time-limited basis.
                                                   implementation and measurement of all of the elements described in the measure to be included in the transition plan would be incredibly labor intensive and may not               This will allow for testing of measure.
                                                   provide much in the way of overall outcomes.

Member       Rita Munley Gallagher,      General   NQF’s efforts to develop a portfolio of care coordination preferred practices and performance measures which provide the structure, process, and outcome measures                  Comment supported current draft, no action necessary
             American Nurses                       required to assess progress toward the care coordination goals and evaluate access, continuity, communication, and tracking of patients across providers and settings
             Association                           are laudable. The American Nurses Association concurs with the intent of the recommended measures and finds them to be significant in improving communication and
                                                   care coordination, a critical element for reform of health care and central to nursing practice in all settings. The American Nurses Association appreciates the futuristic
                                                   nature of NQF’s and the Steering Committee's intention to advance thinking and measurement in this area. This foundational effort is important to improving the quality
                                                   of health care. Care coordination for all populations and in particular for at-risk and vulnerable populations is a major concern to the nursing community. Nursing has
                                                   played a central role in the development and implementation of high risk care coordination models in case management and transitional care. Nursing models of care
                                                   coordination with strong bodies of research, such as Naylor’s Transitional Care Model, support the tenets of care coordination.


Member       Rita Munley Gallagher,      General   The Steering Committee's attention to patient and family engagement, the role of interprofessional teams, and focus on activities at the intersection of professions and Comment supported current draft, no action necessary
             American Nurses                       settings rather than simply adhering to clinical guidelines for referrals or monitoring appointment keeping are critical components of care coordination. As you are aware,
             Association                           nursing has been a champion in all of these areas. The importance placed on patient-centered plan of care with input from all professions within the project is of great
                                                   value in moving the project forward in a collaborative manner.


Member       Rita Munley Gallagher,      General   The American Nurses Association recognizes this work as a critical first step. As noted in the consensus document, several of the endorsed practices have "face          Comment for which no action can be taken in this report.
             American Nurses                       validity", but limited research support. The American Nurses Association understands that the intent of the Steering Committee is to accelerate practice and measures in However, NQF is convening a task force to review evidence
             Association                           this important area, but believes (1) there should be consistent application of the criteria for endorsement of practices and measures and (2) premature endorsement     and grading for measures and practices.
                                                   places undue burden on nurses, physicians and other professionals to implement inadequately tested measures and practices.




                                                                                                                  NQF DRAFT: DO NOT CITE, QUOTE, REPRODUCE, OR CIRCULATE                                                                                                                                 5
Member       Barbara Rudolph, The        General             The Leapfrog Group supports the National Quality Forum's efforts to address the lack of care coordination evident in our current healthcare delivery environment. The      Comment for which no action can be taken. NQF recognizes
             Leapfrog Group                                  Leapfrog Group also supports the effort to develop a comprehensive framework for care coordination measurement. However, the devil is in the details, in particular, the the importance of outcome measures and other NQF projects
                                                             use of terminology that is limiting in terms of application of these metrics. We hope that the National Quality Forum would broaden these preferred practices to all       are currently addressing this issue
                                                             licensed healthcare providers who are delivering "primary care" to patients. In addition, we hope that NQF will quickly address the need for linkage of these practices to
                                                             the outcomes of care. We would like NQF to avoid the same journey through process measures that has occurred with hospital and physician measures.


Non-Member   Samuel Albrect,             General             The Commission for Case Manager Certification (CCMC) is the first and largest organization that certifies case managers across the entire spectrum of health and       Comment for which no action can be taken
             Commission for Case                             human services settings. An independent, not-for-profit organization, the CCMC is accredited by the National Commission for Certifying Agencies (NCCA) and is
             Manager Certification                           overseen by a board of volunteer commissioners representing the scope of professional case management practice. Since 1992, CCMC has awarded more than
                                                             35,000 individuals the Certified Case Manager (CCMC) credential. As of November 1, 2009, 28,015 individuals hold the CCM designation. Those achieving certification
                                                             have demonstrated eligibility based on education and professional background, including licensure or certification to practice as a health and human services clinical
                                                             professional. Achieving the CCM designation initially requires a passing grade on a scientifically valid, research-based certification examination that tests broad
                                                             knowledge of case management. Recertification requires demonstration of ongoing competency through ongoing work experience and continuing education.

                                                             With nearly two decades in case management certification, the CCMC is in a unique position to provide insight into the roles, responsibilities, job functions, and other
                                                             qualifications of case managers, particularly as they relate to care coordination. The CCMC welcomes the opportunity to comment authoritatively on the importance of
                                                             care coordination across the healthcare spectrum.



Non-Member   Samuel Albrect,             General             Reviewing the NQF document, we found numerous opportunities where the certified case manager should be recognized as essential for the activities performed and                    No action taken. Except for practices that demonstrated
             Commission for Case                             achievement of goals and desired outcomes.                                                                                                                                         utilization of a specific care provider, the report refers to care
             Manager Certification                                                                                                                                                                                                              providers who may be any type of health professional with
                                                                                                                                                                                                                                                expertise or certification.

Non-Member   Samuel Albrect,             General             Table 1: Recommended Preferred Practices for National Voluntary Consensus Standards for Care Coordination outlines the domains of care coordination. The CCMC                      No action taken. The committee did not want to single out a
             Commission for Case                             recommends the addition of language in several key places as follows: Number 6, Healthcare Home specifically references a licensed professional in the healthcare                  specific type of care provider. The practice makes reference to
             Manager Certification                           home who would assume responsibilities for the coordination of services. We recommend that this individual be specifically designated as a case manager/care                       the healthcare team, which includes all care providers
                                                             coordinator or other qualified healthcare professional.

Non-Member   Samuel Albrect,             General             Table 1: Recommended Preferred Practices for National Voluntary Consensus Standards for Care Coordination outlines the domains of care coordination. The CCMC No action taken. This type of commiunication shouldn't be
             Commission for Case                             recommends the addition of language in several key places as follows: Similarly, No. 11, Communication, should identify a member of the healthcare home team whose singled to a specifc type of care provider
             Manager Certification                           primary responsibility is communication, ensuring that communication takes place. We recommend that the responsible individual be specifically designated as case
                                                             manager/care coordinator.

Non-Member   Samuel Albrect,             General             Table 1: Recommended Preferred Practices for National Voluntary Consensus Standards for Care Coordination outlines the domains of care coordination. The CCMC                      No action taken. The committee did not want to single out a
             Commission for Case                             recommends the addition of language in several key places as follows: No. 18, Transitions, should also address the need for a healthcare home team member to                       specific type of care provider. The practice makes reference to
             Manager Certification                           assume primary responsibility for assuring safe and effective transitions of care. We recommend the responsible individual be specifically designated as a case                    the healthcare team, which includes all care providers
                                                             manager/care coordinator.

Non-Member   Samuel Albrect,             General             The CCMC has a long history of conducting research, upon which our Certified Case Manager (CCM) credential is based, making it a gold standard in health and human Comment for which no action can be taken
             Commission for Case                             services. Part of our research effort is to ensure that our certification examination is reflective of current case management practice. To that end, the CCMC engages in
             Manager Certification                           a robust national research study, the Role & Functions Study, every five years. Scientifically valid, reliable findings of the study will be submitted for publication in peer-
                                                             reviewed journals in 2010. The CCMC’s latest Role & Functions Study identifies the knowledge and skill domains necessary for effective performance of case
                                                             managers, including knowledge in case management, concepts, healthcare management and delivery, psychosocial aspects of care, healthcare reimbursement,
                                                             rehabilitation, and principles of practice. The CCMC observes that the case management activity, knowledge and skill domains identified in the Role & Functions Study
                                                             can inform the NQF’s Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination. Based on the findings from the Role & Function
                                                             Study, the CCMC would welcome the opportunity to engage in further discussion and to participate in relevant NQF processes. We appreciate this opportunity to submit
                                                             public comment on the NQF Preferred Practices and Measures.

Non-Member   Samuel Albrect,             General             The CCMC applauds the NQF for the development of Measures for Measuring and Reporting Care Coordination Quality. Certified case managers proactively engage in No action taken. While we don't disagree that these measures
             Commission for Case                             measurement and tracking of outcomes as part of evidence-based practice. Based on our expertise, we make the following recommendations: Among the measures                      could be utilized by that population, these measures could be
             Manager Certification                           outlined in the Draft Document, we refer to ―Framework Domain Transitions‖ (lines 1691-1698), which includes three measures that address ―essential and interrelated            applied to any healthcare professionals and are not limited to
                                                             components of the discharge transition for all patients.‖ These components include: ―1, provision of a reconciled medication list to patients and/or caregivers at hospital case managers.
                                                             discharge; 2, provision of the transition plan of care to the patient and/or caregivers at hospital discharge; and 3, provision of the transition plan of care to the receiving
                                                             provider(s) at hospital discharge.‖ These measures are within the scope of practice of certified case managers to improve patient safety and quality of services
                                                             provided, and to address specific outcomes related to reoccurrence and readmission. Certified case managers strive to improve transitions by implementing plans of
                                                             care that extend beyond discharge to encompass all levels of care. Therefore, the CCMC recommends that the Framework Domain Transitions language specify the
                                                             role of case manager/care coordinator and specifically distinguish that certified case managers are required to do this as part of their professional practice while others
                                                             may not.

Non-Member   Sandra Lowery, CCMI         General             Table 1, p. 11 Plans need to be agreed upon by the client/patient.                                                                                                                 No action taken. Commentor reviewed only the short table of
             Associates                                                                                                                                                                                                                         the practice statements. This point is addressed within the
                                                                                                                                                                                                                                                specifications of Practice 6.
Non-Member   Sandra Lowery, CCMI         General             Line 1213 This is too prescriptive, i.e. daily hospital visits. I recommend at least one hospital visit and then as needed.                                                        No action taken. The evidence base for this practice is well
             Associates                                                                                                                                                                                                                         supported with the current model of a transitional care nurse.

Non-Member   Sandra Lowery, CCMI         General             Line 1242 TCM should not substitute for home care nursing, allowing the care coordinator to serve in an objective role, unless only care coordination is needed and not            No action taken. The evidence base for this practice is well
             Associates                                      clinical care.                                                                                                                                                                     supported with the current model of having a transitional care
                                                                                                                                                                                                                                                nurse
Non-Member   Sandra Lowery, CCMI         General             Line 1270 Adding the clinical status to the functional status would be more comprehensive.                                                                                         Comment incorporated into report
             Associates



Non-Member   Bonnie Sanderson, Auburn    Measure CC-019-09   Despite the complexity and logistic challenges in the acute care setting, the opportunity cannot be missed to initiate a Cardiac rehab (CR) referral for diagnosis-eligible        Developer Response: We agree with these comments. No
             University                                      patients in the acute care. Benefits of cardiac rehab within care coordination are numerous: risk factor control, medication adherence, lifestyle counseling. improve              further action needed.
                                                             functional capacity and quality of life, return to work, reduced mortality, etc.) Secondary prevention measures are already collected as core measures among patients
                                                             with heart disease, adding the assessment of CR would add minimal additional work to this collection. Connection of the hospital team to the CR team is an essential
                                                             communication and care-coordination step in transitioning care from hospital to after-care and guiding patients to achieve necessary risk-reduction goals.



Member       Carol Sakala, Childbirth    Measure CC-019-09   It is unclear how this measure will actually result in coordinated care for cardiac patients, as there is no closure to the measured referral loop. The current measure only       No action taken. Committee recognized this, but this measure
             Connection                                      collects data on whether a patient was referred to rehab from the inpatient setting but not the crucial matter of whether the patient received rehab services. There is no         is a first step to address this important aspect of a certain
                                                             way to know whether a patient has contacted a rehab facility and entered a rehab program, a crucial care coordination connection.                                                  patient population

Member       Christine Chen, Pacific     Measure CC-019-09   Cardiac Rehab Patient Referral from Inpatient Setting (CC-019-09): It is not clear how this measure will actually result in coordinated care for cardiac patients. There is        No action taken.
             Business Group on Health                        no closure to the referral loop measured. This measure only collects data on whether a patient was referred to rehab from the in-patient setting, and not whether the
                                                             patient actually attended rehab. While the measure also specifies that the referring hospital must contact the rehab facility, there is no way to know if the patient ever
                                                             contacts the facility and enters a rehab program. This is not reflective of care coordination.
Member       Debra Ness, National      Measure CC-019-09     This measure is troubling in that there is no way of knowing whether the referral loop is closed since it only collects data on whether a patient was referred to rehab from No action taken. Committee recognized this, but this measure
             Partnership for Women and                       the in-patient setting, and not whether the patient actually attended rehab. This is not reflective of care coordination.                                                    is a first step to address this important aspect of a certain
             Families                                                                                                                                                                                                                     patient population

Member       Gayle Fortner, HC21         Measure CC-019-09   It is not clear how this measure will actually result in coordinated care for cardiac patients. There is no closure to the referral loop measured. This measure only collects      No action taken.
                                                             data on whether a patient was referred to rehab from the in-patient setting, and not whether the patient actually attended rehab. While the measure also specifies that the
                                                             referring hospital must contact the rehab facility, there is no way to know if the patient ever contacts the facility and enters a rehab program. This is not reflective of care
                                                             coordination.



Member       Janet Leiker, American    Measure CC-019-09     There is no mention of a direct connection to the primary care physician (or other physician) in the patient's community.                                                          Developer Response: The commenter is correct. The
             Academy of Family                                                                                                                                                                                                                  connection between the primary cardiovascular care provider
             Physicians. Commission on                                                                                                                                                                                                          and the cardiac rehabilitation program staff was included in the
             Quality and Practice                                                                                                                                                                                                               cardiac rehabilitation program performance measures that the
                                                                                                                                                                                                                                                Committee elected not to recommend as part of the Care
                                                                                                                                                                                                                                                Coordination Project. Reasons for not recommending
                                                                                                                                                                                                                                                measures were (1) measure was viewed as a guideline, not a
                                                                                                                                                                                                                                                suitable metric and (2) measure focused on risk assessment
                                                                                                                                                                                                                                                and not coordinating care

Member       Laura Blum, The Heart       Measure CC-019-09   The Heart Rhythm Society applauds this measure as an opportunity to assess the quality of the patients transition from the inpatient hospital setting to an outpatient             Developer Response: Further clarity was added to the
             Rhythm Society                                  cardiac rehabilitation program. Referral to an outpatient cardiac rehabilitation program prior to hospital discharge will promote timely communication and appropriate and         specifications of the measure: "This also includes a written or
                                                             accurate information transfer, and improved healthcare outcomes. As recognized in the Steering Committees report, this measure is supported by evidence                            electronic communication between the healthcare provider or
                                                             demonstrating that patients, who participate in cardiac rehabilitation, have better outcomes. To clarify the intent of the measure to support patient involvement in the           healthcare system and the cardiac rehabilitation program that
                                                             referral process, all communication and transfer of information should be accompanied by written or electronic documentation which is: 1) shared with the patient; 2) is           includes the patient's enrollment information for the program."
                                                             presented in a format that is understandable to the patient and caregivers, and; 3) is included with the patients discharge plan. As underlined above, the Heart Rhythm
                                                             Society suggests that NQF add the words written or electronic to clarify the type of required documentation.


Member       Phelan Michael, Cleveland   Measure CC-019-09   Our review of the meta analysis is that the data is relatively weak for mortality with a RR reduction of 20 % but CI that cross or approaches 1 suggesting this may not be Developer Response: No action taken. Published data show
             Clinic                                          significant. The data is stronger for MI reduction but only if the program includes exercise. The authors conclude " the interventions varied substantially and reduced    that referral processes that do include a direct contact with the
                                                             subsequent MI and mortality the widespread application should rigorously evaluate long term clinical and economic outcomes..."                                             CR program help to reduce the referral/enrollment gap for CR
                                                                                                                                                                                                                                        participation.
                                                             Bottom line the inpatient cardiac rehab process is a good measure and makes sense, has some reasonable evidence to back it up and can be implemented and audited
                                                             reasonably well. The additional requirement to notify the rehab center is more problematic in terms of compliance and as we discussed would be best eliminated. Giving
                                                             the patient a discharge summary or instruction sheet should suffice.

                                                             Recommendation would be to encourage the NQF to focus on and support the inpatient measure with simplification of the measure as its first step.



Non-Member   Renee Demski, Johns         Measure CC-019-09   First, there implicit asymmetry/discrimination in discharge-based cardiac core measures. A primary-care hospital that transfers most of its patients for                           Developer Response: No action taken. Published evidence
             Hopkins Medicine                                angiography/revascularization will sail by such measures, because it has few discharges to home; a tertiary-care hospital will get consistently dinged. The denominator            shows that cardiac rehabilitation (CR) is associated with
                                                             for this measure is impossibly broad. Many patients who are coded as acute MI have complete revascularization by PCI, normal ejection fraction, trivial cardiac enzyme             improvements in morbidity and mortality in lower, moderate, or
                                                             evidence of myocardial necrosis. They don't need rehab. Unless the exclusions are broadened to use ejection fraction or cardiac enzymes (e.g. EF <40%, troponin-I                  higher risk patients following a cardiac event, including those
                                                             >~30) this measure is ridiculous. The studies supporting cardiac rehab are done in sick patients, not those with trivial events. From a JHH perspective, perhaps half of           undergoing percutaneous coronary interventions (PCI).
                                                             our angioplasty patients would inappropriately qualify for this metric. Also, the metric doesn't distinguish between cardiac surgery patients (who almost all warrant rehab),      Patients in such settings are referred to a CR program nearest
                                                             acute MI patients (who often but not always need rehab), and chronic stable angina patients (who may have had chronic stable angina for years, are well managed, had               their home, a process that is done by telephone, fax, or
                                                             PCI after small ACS, and have no indication for rehab. The drafting on this measure seems to be egregiously broad.                                                                 electronic communication as easily in smaller hospitals as it is
                                                                                                                                                                                                                                                in larger ones. A national database of CR programs, with
                                                                                                                                                                                                                                                contact information, is available for free on the internet at
                                                                                                                                                                                                                                                www.aacvpr.org.



Non-Member   Renee Demski, Johns         Measure CC-019-09   Metrics related to cardiac patients are ambiguous and too broad. Not every patient needs cardiac rehab, therefore a higher percentage would not necessarily be                     Developer Response: No action taken. Published data show
             Hopkins Medicine                                reflective of better care quality or coordination.                                                                                                                                 that referral processes that do include a direct contact with the
                                                                                                                                                                                                                                                CR program help to reduce the referral/enrollment gap for CR
                                                                                                                                                                                                                                                participation.


Non-Member   Steven Lichtman, Helen      Measure CC-019-09   I would like to thank NQF for this opportunity to respond to the Standards for Measuring and Reporting Care Coordination for Cardiac Rehabilitation, specifically Cardiac Comment supports draft report
             Hayes Hospital                                  Rehab Patient Referral from Inpatient Setting (CC-019-09). Cardiac rehabilitation has a well documented and high level of peer reviewed evidence supporting its efficacy
                                                             as an essential component in the post acute care of the patient with cardiac disease. Cardiac rehabilitation has consistently demonstrated a significant independent
                                                             effect toward decreasing morbidity and mortality, as well as many other psychosocial and secondary benefits. What has been missing from the practice of cardiac
                                                             rehabilitation is a documented process connecting patients who have experienced a cardiac event with ongoing outpatient rehabilitation. Many other measures of
                                                             secondary prevention are already collected as core measures. The addition of implementing an inpatient cardiac rehabilitation process with communication between the
                                                             inpatient and outpatient facility is a relativity easy protocol and will make significant strides toward ensuring that patients with cardiac disease receive the standard of
                                                             care they deserve. The communication link is essential, as data in peer reviewed studies demonstrate that without a direct link, referral is low, even when patients are
                                                             verbally encouraged to attend rehabilitation. I recommend that this measure be supported and implemented as proposed.


Member       Angela Franklin, American   Measure CC-020-09   ACEP recommends clarification that this measure does not apply to the ED outpatient setting.                                                                                       Developer Response: No action taken. Agree with the
             College of Emergency                                                                                                                                                                                                               commenter that emergency departments should be explicitly
             Physicians                                                                                                                                                                                                                         excluded from the cardiac rehabilitation performance measures
                                                                                                                                                                                                                                                since the ED staff is not responsible for a patient's hospital
                                                                                                                                                                                                                                                discharge planning, nor for a patient's ongoing outpatient care.
                                                                                                                                                                                                                                                We specified in item 15 of the application form that the
                                                                                                                                                                                                                                                performance measure did not apply in the ED setting.




                                                                                                                           NQF DRAFT: DO NOT CITE, QUOTE, REPRODUCE, OR CIRCULATE                                                                                                                                    6
Member       Barbara Rudolph, The        General             The Leapfrog Group supports the National Quality Forum's efforts to address the lack of care coordination evident in our current healthcare delivery environment. The      Comment for which no action can be taken. NQF recognizes
             Leapfrog Group                                  Leapfrog Group also supports the effort to develop a comprehensive framework for care coordination measurement. However, the devil is in the details, in particular, the the importance of outcome measures and other NQF projects
                                                             use of terminology that is limiting in terms of application of these metrics. We hope that the National Quality Forum would broaden these preferred practices to all       are currently addressing this issue
                                                             licensed healthcare providers who are delivering "primary care" to patients. In addition, we hope that NQF will quickly address the need for linkage of these practices to
                                                             the outcomes of care. We would like NQF to avoid the same journey through process measures that has occurred with hospital and physician measures.


Non-Member   Bonnie Sanderson, Auburn    Measure CC-020-09   Although CC-019-09 addresses inpatient CR referral, there is a need and an opportunity to address the needs of patients who are eligible for important CR services, yet           Developer Response: We agree with the commenter. No
             University                                      were not hospitalized for an acute event, or "fell through the cracks" and did not receive a referral in the acute care setting. Secondary prevention measures are already        further action needed.
                                                             established as important care indicators. Adding CR referral within other important measures is achievable and necessary to help patients with cardiac disease achieve
                                                             important risk-reduction and life-saving benefits.

Member       Carol Sakala, Childbirth    Measure CC-020-09   As with our comments about the companion inpatient measure, without an element in the measure specification requiring demonstration that the patient actually                     No action taken. Committee recognized this, but this measure
             Connection                                      participated in a rehab program, we feel that this measure falls short of reasonable care coordination standards.                                                                 is a first step to address this important aspect of a certain
                                                                                                                                                                                                                                               patient population


Member       Christine Chen, Pacific     Measure CC-020-09   Cardiac Rehab Patient Referral from Outpatient Setting (CC-020-09): As with our comments on CC-019-09, without a component to the measure specification that will         No action taken. Committee recognized this, but this measure
             Business Group on Health                        require proof that a patient followed-through with attending rehabilitation, this measure will not achieve the care coordination goals outlined by the steering committee.is a first step to address this important aspect of a certain
                                                                                                                                                                                                                                       patient population
Member       Debra Ness, National      Measure CC-020-09     As with our comments on CC-019-09, without a component to the measure specification that will require proof that a patient followed-through with attending                No action taken. Committee recognized this, but this measure
             Partnership for Women and                       rehabilitation, this measure will not achieve the care coordination goals outlined by the steering committee.                                                             is a first step to address this important aspect of a certain
             Families                                                                                                                                                                                                                  patient population
Member       Gayle Fortner, HC21       Measure CC-020-09     As with my comments on CC-019-09, without a component to the measure specification that will require proof that a patient followed-through with attending rehabilitation, No action taken. Committee recognized this, but this measure
                                                             this measure will not achieve the care coordination goals outlined by the steering committee.                                                                             is a first step to address this important aspect of a certain
                                                                                                                                                                                                                                       patient population
Member       Janet Leiker, American    Measure CC-020-09     There is no mention of a direct connection to the primary care physician (or any physician) in the patient's community.                                                   No action taken. The connection between the primary
             Academy of Family                                                                                                                                                                                                         cardiovascular care provider and the cardiac rehabilitation
             Physicians. Commission on                                                                                                                                                                                                 program staff was included in the cardiac rehabilitation
             Quality and Practice                                                                                                                                                                                                      program performance measures that NQF elected not to
                                                                                                                                                                                                                                       recommend as part of the Care Coordination Project.
                                                                                                                                                                                                                                       Reasons for not recommending measures were (1) measure
                                                                                                                                                                                                                                       was viewed as a guideline, not a suitable metric and (2)
                                                                                                                                                                                                                                       measure focused on risk assessment and not coordinating
                                                                                                                                                                                                                                       care
Member       Laura Blum, The Heart       Measure CC-020-09   The Heart Rhythm Society supports the Steering Committees recommendation that a standardized definition of the outpatient setting would clarify the intent of this                Further specificity defining the outpatient setting was added to
             Rhythm Society                                  measure. The measure title includes the term outpatient setting while the numerator is patients in an outpatient practice and the denominator specifies patients in an            the draft report. We supplied the specification of the outpatient
                                                             outpatient clinical practice. A definition of the outpatient setting along with standardized terminology (e.g., outpatient setting) would strengthen the usability of this        setting on the NQF application form. If NQF requires additional
                                                             measure.                                                                                                                                                                          specification beyond what was requested on the application
                                                                                                                                                                                                                                               form, we would be happy to respond.


Member       Phelan Michael, Cleveland   Measure CC-020-09   As for the outpatient setting measure it makes little sense to me and will be much more difficult to audit. Also the evidence supporting a referral 11 months after CABG or Developer Response: No action taken. The Center for
             Clinic                                          MI is lacking. Logically if hospitals focus on 100% compliance with the inpatient/discharge measure there will be no need for the outpatient referral audit. Practically how Medicare and Medicaid (CMS) policies for cardiac
                                                             to audit and assess every patient's referral to or attendance at cardiac rehab months after the event will be difficult and time consuming. Seems to me one measure-         rehabilitation coverage are consistent with the specified time
                                                             inpatient to rehab show be the focus.                                                                                                                                        interval for referral included in the measure. Published
                                                                                                                                                                                                                                          evidence also shows positive patient outcomes due to CR,
                                                             The Numerator details in each measure is different- for the outpatient referral there is a mandate for OPD doctor and rehab personnel to communicate while this is not       even beyond 12 months from the time of the qualifying cardiac
                                                             necessary in the inpatient process. Not sure why.                                                                                                                            event. Current practice includes written, electronic and verbal
                                                                                                                                                                                                                                          communication between CR program staff and the primary
                                                             NQF should revisit the outpatient process with simplification and modification as necessary and justify way it is necessary if the inpatient measure is successfully         cardiovascular healtcare provider, to track patient progress and
                                                             implemented.                                                                                                                                                                 update patient care needs. Tracking of CR participation will
                                                                                                                                                                                                                                          reinforce this communication, as well as the actual referral of
                                                                                                                                                                                                                                          appropriate patients to CR.


Member       Phelan Michael, Cleveland   Measure CC-020-09   This measure should explicitly exclude the ED. Without an explicit ed exclsuion an ed may get bundled where it wouldnt be approriate                                              Developer Response: No action taken. It is agreed that
             Clinic                                                                                                                                                                                                                            emergency departments should be explicitly excluded from the
                                                                                                                                                                                                                                               cardiac rehabilitation performance measures since the ED staff
                                                                                                                                                                                                                                               is not responsible for a patient's hospital discharge planning,
                                                                                                                                                                                                                                               nor for a patient's ongoing outpatient care. We specified in
                                                                                                                                                                                                                                               item 15 of the application form that the performance measure
                                                                                                                                                                                                                                               did not apply in the ED setting.

Non-Member   Renee Demski, Johns         Measure CC-020-09   This measure has similar problems. It doesn't distinguish between patients who are sick and didn't get rehab, and those who are so well that they never needed rehab.             Developer Response: No action taken. Published evidence
             Hopkins Medicine                                                                                                                                                                                                                  shows that cardiac rehabilitation (CR) is associated with
                                                                                                                                                                                                                                               improvements in morbidity and mortality in lower, moderate, or
                                                                                                                                                                                                                                               higher risk patients following a cardiac event, including those
                                                                                                                                                                                                                                               undergoing percutaneous coronary interventions (PCI). In
                                                                                                                                                                                                                                               addition, the commenter's concerns about tertiary hospitals is
                                                                                                                                                                                                                                               unfounded. Patients in such settings are referred to a CR
                                                                                                                                                                                                                                               program nearest their home, a process that is done by
                                                                                                                                                                                                                                               telephone, fax, or electronic communication as easily in smaller
                                                                                                                                                                                                                                               hospitals as it is in larger ones. A national database of CR
                                                                                                                                                                                                                                               programs, with contact information, is available for free on the
                                                                                                                                                                                                                                               internet at www.aacvpr.org.


Non-Member   Steven Lichtman, Helen      Measure CC-020-09   Again, I would like to thank NQF for this opportunity to respond to the Standards for Measuring and Reporting Care Coordination for Cardiac Rehabilitation, specifically Comment supports draft report
             Hayes Hospital                                  Cardiac Rehab Patient Referral from Outpatient Setting (CC-020-09). As stated in my response to Cardiac Rehab Patient Referral from Inpatient Setting (CC-019-09),
                                                             cardiac rehabilitation has a well documented and high level of peer reviewed evidence supporting its efficacy as an essential component in the post acute care of the
                                                             patient with cardiac disease. Cardiac rehabilitation has consistently demonstrated a significant independent effect toward decreasing morbidity and mortality as well as
                                                             many other psychosocial and secondary. What has been missing from the practice of cardiac rehabilitation is a documented process connecting patients who have
                                                             experienced a cardiac event with ongoing outpatient rehabilitation. However, implementing a process of referral and communication from the acute inpatient setting to
                                                             outpatient cardiac rehabilitation is necessary but not sufficient. The are a number of patients with an eligible diagnosis who are never seen in the inpatient setting after an
                                                             acute event, but are diagnosed and managed directly from the physicians office. Additionally, requiring referral from the outpatient setting will catch many of the patients
                                                             seen in the acute setting who, for one reason or another, do not receive appropriate referral to outpatient cardiac rehabilitation. I recommend that this measure be
                                                             supported and implemented as proposed.


Member       Angela Franklin, American   Measure CC-050-09   ACEP recommends clarification regarding physician accountability for this measure. Specifically, emergency physicians should not be held accountable for the patient              Developer Response: The primary intent of this measure is to
             College of Emergency                            receiving follow-up within 14 days of the initiating facility event and/or the professional encounter during the POST period, as this is not within their control. Also, as TIA   facilitate care coordination, not assign physician accountability.
             Physicians                                      coding is highly variable, ACEP recommends more specific/universally-used coding to clarify the scope of the measure.                                                             This measure will identify patients who need prompt follow up
                                                                                                                                                                                                                                               care. ER physicians/staff can faciliate the process by outlining
                                                                                                                                                                                                                                               a clear ER discharge plan that includes recommended follow up
                                                                                                                                                                                                                                               care. Care/disease management vendors and customers who
                                                                                                                                                                                                                                               share this information with physicians to improve patient care
                                                                                                                                                                                                                                               can use this measure to identify patients in need prompt follow
                                                                                                                                                                                                                                               up care who have not received it. This measure can also
                                                                                                                                                                                                                                               evaluate the effectiveness of systems, including medical
                                                                                                                                                                                                                                               homes, as we look for quality improvement opportunties.
                                                                                                                                                                                                                                               Regarding coding, for denominator inclusion the patient must
                                                                                                                                                                                                                                               have an ER encounter accomplanied by a very specific TIA
                                                                                                                                                                                                                                               code (435.X).


Member       Belinda Ireland, BJC        Measure CC-050-09   This measure, as currently specified, excludes one of the most vulnerable populations, those without regular access to care. Because the measure developer (a health              Although the developer is a health plan, the NQF endorsement
             Healthcare                                      plan) is only interested in continuously enrolled members, the denominator statement restricts this measure to that population. This is a problem for broader                     is at all levels of analysis and so this measure is not limited to
                                                             implementation                                                                                                                                                                    continuously enrolled measures. The denominator wil be
                                                                                                                                                                                                                                               reviewed to address comment

Member       Deborah Donovan,            Measure CC-050-09   The measure did not seem to define the type of practitioner visit that would be considered for compliance. For example, would a dermatology visit satisfy the                     Developer Response: The primary intent of this measure is to
             Highmark Inc                                    requirement? We recommend further define the type of provider for the follow up visit following the transient cerebral ischemic event.                                            facilitate care coordination, not assign physician accountability.
                                                                                                                                                                                                                                               This measure will identify patients who need prompt follow up
                                                                                                                                                                                                                                               care. In addition, numerator compliance requires a provider
                                                                                                                                                                                                                                               face-to-face encounter accompanied by a code for occlusive
                                                                                                                                                                                                                                               vascular disease, non-hemorrhagic stroke, or TIA. These
                                                                                                                                                                                                                                               codes are only included on a provider encounter claim when the
                                                                                                                                                                                                                                               provider has addressed the condition/problem. It is highly
                                                                                                                                                                                                                                               unlikey a dermatologist would submit one of these codes with
                                                                                                                                                                                                                                               their patient encounter claim.ease


Member       Phelan Michael, Cleveland   Measure CC-050-09   Re: ER TIA (CC-059-09)                                                                                                                                                            Developer Response: The primary intent of this measure is to
             Clinic                                          We would vote against the measure as written. Needs further work and explanation of what they are trying to measure with this metric.                                             facilitate care coordination, not assign physician accountability.
                                                             What are they trying to achieve with this measure? Are they measuring the actual patients that go back for follow up( is this a patient responsibility measure, or an ED md       This measure will identify patients who need prompt follow up
                                                             responsibility measure ( who wouldn’t?)whether ED physicians are giving the pt appropriate follow up ie phone numbers to make an appointment, or health care                      care. ER physicians/staff can faciliate the process by outlining
                                                             organization's the ability to accomodate a patient ie get into an appointment for follow up. What about the poor or disenfranchised patients? They may decide not to go           a clear ER discharge plan that includes recommended follow up
                                                             in for follow up. Who is going to take it on the chin for this measure? We are not clear.                                                                                         care. Care/disease management vendors and customers who
                                                             We realize the reason this is being included is because of the data concerning TIA pts and bad outcomes within 30 days. However consider the following:                           share this information with physicians to improve patient care
                                                             TIA: why is the ED even being considered for this type of measurement? Currently TIA’s which used to be an outpatient follow up type appointment but now any one with             can use this measure to identify patients in need prompt follow
                                                             this diagnosis seems to have moved into a ―must consult neurology or even admit for testing‖ wither while in the ed or place in observation for continued next comment)           up care who have not received it. This measure can also
                                                                                                                                                                                                                                               evaluate the effectiveness of systems, including medical
                                                                                                                                                                                                                                               homes, as we look for quality improvement opportunties.


Member       Phelan Michael, Cleveland   Measure CC-050-09   a neurologist to make recommendations about diagnostic testing. Some of this testing is being done during ed/obs visit. We are not sure what’s happening in other      Comment for which no action can be taken
             Clinic                                          hospitals or even in the community based ED’s...yes they warrant evaluation but some of these patients probably merit some sort of complete workup prior to discharge.


Member       Phelan Michael, Cleveland   Measure CC-050-09   Measuring whether a patient receives follow up with 2 weeks of the visits is trying to measure what?( continued on next comment)                                 1. Patient       Developer Response: The primary intent of this measure is to
             Clinic                                          Compliance or ED’s recommendation with for a follow visit?                                                                                                                        facilitate care coordination, not assign physician accountability.
                                                             2. Whether ed actually recommend fu?                                                                                                                                              This measure will identify patients who need prompt follow up
                                                             3. Did the hospital/HCO provide appropriate open acess for an appointment                                                                                                         care. ER physicians/staff can faciliate the process by outlining
                                                             What about patients who already received appropriate testing in the ED or in observation unit; These patients do not need follow so quickly.                                      a clear ER discharge plan that includes recommended follow up
                                                                                                                                                                                                                                               care. Care/disease management vendors and customers who
                                                             Is there any data to suggest that follow up within 2 weeks following either ED visit or hospitalization for TIA improves secondary prevention? WE know there is a high            share this information with physicians to improve patient care
                                                             event rate based on the Kaiser studies. How does improved access to follow up change this.                                                                                        can use this measure to identify patients in need prompt follow
                                                                                                                                                                                                                                               up care who have not received it. This measure can also
                                                                                                                                                                                                                                               evaluate the effectiveness of systems, including medical
                                                                                                                                                                                                                                               homes, as we look for quality improvement opportunties.


Non-Member   Renee Demski, Johns         Measure CC-050-09   Measure says visit with any physician within 14 days. An internist, cardiologist or neurologist would make sense. A podiatrist, gynecologist or otolaryngologist would not        Developer Response: The primary intent of this measure is to
             Hopkins Medicine                                make sense to qualify for this requirement. Also, how will the hospital know whether such visit took place? We can make the recommendation and make sure it is written            facilitate care coordination, not assign physician accountability.
                                                             down for the patient and family on discharge, but we would not know whether patient followed up on it.                                                                            This measure will identify patients who need prompt follow up
                                                                                                                                                                                                                                               care. ER physicians/staff can faciliate the process by outlining
                                                                                                                                                                                                                                               a clear ER discharge plan that includes recommended follow up
                                                                                                                                                                                                                                               care. Care/disease management vendors and customers who
                                                                                                                                                                                                                                               share this information with physicians to improve patient care
                                                                                                                                                                                                                                               can use this measure to identify patients in need prompt follow
                                                                                                                                                                                                                                               up care who have not received it. This measure can also
                                                                                                                                                                                                                                               evaluate the effectiveness of systems, including medical
                                                                                                                                                                                                                                               homes, as we look for quality improvement opportunties. Also,
                                                                                                                                                                                                                                               this measure would identify encounters that occur in a hospital
                                                                                                                                                                                                                                               setting.



Member       Belinda Ireland, BJC        Measure CC-071-09   The NQF draft description does not match that provided by the developer in the measure submission form. That describes the measure as only for logging (recording)                The measure developer provided further clarity on the measure
             Healthcare                                      the biospy. It does not include any measure of communication to patient and referring physician, which is an essential part of this measure.                                      to indicate that communication between the referring physician
                                                                                                                                                                                                                                               and the primary care physician and patient must take place.




                                                                                                                           NQF DRAFT: DO NOT CITE, QUOTE, REPRODUCE, OR CIRCULATE                                                                                                                                   7
Member       Barbara Rudolph, The         General             The Leapfrog Group supports the National Quality Forum's efforts to address the lack of care coordination evident in our current healthcare delivery environment. The      Comment for which no action can be taken. NQF recognizes
             Leapfrog Group                                   Leapfrog Group also supports the effort to develop a comprehensive framework for care coordination measurement. However, the devil is in the details, in particular, the the importance of outcome measures and other NQF projects
                                                              use of terminology that is limiting in terms of application of these metrics. We hope that the National Quality Forum would broaden these preferred practices to all       are currently addressing this issue
                                                              licensed healthcare providers who are delivering "primary care" to patients. In addition, we hope that NQF will quickly address the need for linkage of these practices to
                                                              the outcomes of care. We would like NQF to avoid the same journey through process measures that has occurred with hospital and physician measures.


Member       Deborah Donovan,             Measure CC-071-09   The description of the measure for biopsy appears very broad. Could the measure be further defined by the types of biopsy? Does this include all inpatient and                   Developer Response: For patient safety, a biopsy log should
             Highmark Inc                                     outpatient biopsies?                                                                                                                                                             be kept on all biopsies taken by all medical practitioners in the
                                                                                                                                                                                                                                               inpatient and outpatient setting. However, we acknowledge that
                                                                                                                                                                                                                                               our specifications (see comment # 187) apply to the outpatient
                                                                                                                                                                                                                                               setting and accordingly have changed the measure scope to
                                                                                                                                                                                                                                               indicate it is specified for ambulatory care.

Member       Rebecca Zimmermann,          Measure CC-071-09   The data collection methodology for this measure is medical record review. AHIP recommends that specifications for alternative data sources, such as EHRs, be                    Developer Response: A biopsy log is essentially a registry.
             AHIP                                             provided.                                                                                                                                                                        Ideally, such a log would be incorporated into routine
                                                                                                                                                                                                                                               processes and would be generated automatically from
                                                                                                                                                                                                                                               electronic records whenever a biopsy is performed. If an
                                                                                                                                                                                                                                               automatic log is not created it should be maintained in some
                                                                                                                                                                                                                                               other fashion, either electronic or, if necessary, on paper. We
                                                                                                                                                                                                                                               have applied to AMA for CPTII codes that would also allow this
                                                                                                                                                                                                                                               measure to be coded from outpatient claims data. Code
                                                                                                                                                                                                                                               A:biopsy performed and entered into tracking log; code B1:
                                                                                                                                                                                                                                               biopsy results reviewed, entered into tracking log and
                                                                                                                                                                                                                                               communicated to patient or patient's guardian/caregiver and to
                                                                                                                                                                                                                                               Patient's PCP and/or other physician/professional responsible
                                                                                                                                                                                                                                               for follow-up care; code B2: biopsy results reviewed, entered
                                                                                                                                                                                                                                               into tracking log and communicated to patient or patient's
                                                                                                                                                                                                                                               guardian/caregiver (patient does not wish results to be
                                                                                                                                                                                                                                               communicated to PCP or patient does not have a PCP and
                                                                                                                                                                                                                                               there is no other physician/professional responsible for follow-
                                                                                                                                                                                                                                               up care).


Non-Member   Renee Demski, Johns          Measure CC-071-09   In addition to concerns that this metric is very broad, there are also circumstances in which the patient self-refers and/or information about the primary care physician is     Developer Response: A biopsy log is essentially a registry.
             Hopkins Medicine                                 unavailable.                                                                                                                                                                     Ideally, such a log would be incorporated into routine
                                                                                                                                                                                                                                               processes and would be generated automatically from
                                                                                                                                                                                                                                               electronic records whenever a biopsy is performed. If an
                                                                                                                                                                                                                                               automatic log is not created it should be maintained in some
                                                                                                                                                                                                                                               other fashion, either electronic or, if necessary, on paper. We
                                                                                                                                                                                                                                               have applied to AMA for CPTII codes that would also allow this
                                                                                                                                                                                                                                               measure to be coded from outpatient claims data. Code
                                                                                                                                                                                                                                               A:biopsy performed and entered into tracking log; code B1:
                                                                                                                                                                                                                                               biopsy results reviewed, entered into tracking log and
                                                                                                                                                                                                                                               communicated to patient or patient's guardian/caregiver and to
                                                                                                                                                                                                                                               Patient's PCP and/or other physician/professional responsible
                                                                                                                                                                                                                                               for follow-up care; code B2: biopsy results reviewed, entered
                                                                                                                                                                                                                                               into tracking log and communicated to patient or patient's
                                                                                                                                                                                                                                               guardian/caregiver (patient does not wish results to be
                                                                                                                                                                                                                                               communicated to PCP or patient does not have a PCP and
                                                                                                                                                                                                                                               there is no other physician/professional responsible for follow-
                                                                                                                                                                                                                                               up care).



Member       Barbara Rudolph, The         Measure CC-073-09   A reconciled medication list is clearly a baseline measure for informing patients of the medications being used following discharge. One of the principal reasons for     No action taken.
             Leapfrog Group                                   hospital readmissions is failure by patients to follow-through or overdose with medications post-discharge. It is critical for a knowledgeable healthcare professional to
                                                              provide information to patients that is understandable--and that provides them with a resource they can follow-up with when they have questions at home. Patients should
                                                              be able to (in their own words) describe why they need the medication, and where they can get help if they have issues with the medication when they arrive home. A
                                                              checkbox that the med rec was given to patient--does not suffice.
Member       Belinda Ireland, BJC         Measure CC-073-09   This measure adds important details to previous medication reconcilliation measures by requiring complete information on medication changes (start and stop) and          Comment for which no action can be taken
             Healthcare                                       dosages and use instructions.

Member       Carol Sakala, Childbirth     Measure CC-073-09   Simply checking a box stating that a patient has received a list of medications is not adequate for meeting standards relating to the crucial matter of medication               Committee concurs that patient education is an important
             Connection                                       reconciliation. Education to ensure that the medical professional believes that the patient and/or designees understand and can follow the medication regimen is an              element to medication reconciliation. This measures is a first
                                                              essential component. The patient and designees also require access to phone follow up for any further questions.                                                                 step in the process of addressing care coordination

Member       Christine Chen, Pacific      Measure CC-073-09   Reconciled Medication List Received by Discharged Patients (CC-073-09): While medication reconciliation is obviously an integral component to care coordination and Committee recognized this, but this measure is a first step to
             Business Group on Health                         care transitions, simply checking a box saying that a patient received a list of medications is not sufficient. There needs to a patient education component that indicates address this important aspect of a certain patient population
                                                              that the medical professional providing the reconciliation instructions feels completely assured that the patient and/or caregiver understands them and can follow them.
                                                              This requires making sure that the patient and/or caregiver received the information, understood it, and were given supporting materials that either they, or an appropriate
                                                              caregiver/family member, understood and would be able to implement the medication regimen once leaving the hospital or other setting. These supporting materials
                                                              must include the name and contact information that a patient and/or caregiver can access at any time if they have further questions once they actually attempt to comply
                                                              with the protocol after leaving a facility. This is particularly crucial for patients for whom the medication protocol may be modified depending on the patients progress
                                                              post-discharge. Without making sure that the measure specifications address these concerns, we would not be able to support this measure.



Member       Debra Ness, National      Measure CC-073-09      While medication reconciliation is obviously an integral component to care coordination and care transitions, simply checking a box saying that a patient received a list of Committee concurs that patient education is an important
             Partnership for Women and                        medications is not sufficient. There needs to a patient education component that indicates that the medical professional providing the reconciliation instructions feels          element to medication reconiliation. This measures is a first
             Families                                         completely assured that the patient and/or caregiver understands them and can follow them. This requires making sure that the patient and/or caregiver received the               step in the process of addressing care coordination
                                                              information, understood it, and were given supporting materials that either they, or an appropriate caregiver/family member, understood and would be able to implement
                                                              the medication regimen once leaving the hospital or other setting. These supporting materials must include the name and contact information that a patient and/or
                                                              caregiver can access at any time if they have further questions once they actually attempt to comply with the protocol after leaving a facility. This is particularly crucial for
                                                              patients for whom the medication protocol may be modified depending on the patients progress post-discharge. Without making sure that the measure specifications
                                                              address these concerns, we would not be able to support this measure.

Member       Gayle Fortner, HC21          Measure CC-073-09   While medication reconciliation is obviously an integral component to care coordination and care transitions, simply checking a box saying that a patient received a list of Committee recognized this, but this measure is a first step to
                                                              medications is not sufficient. There needs to a patient education component that indicates that the medical professional providing the reconciliation instructions feels          address this important aspect of a certain patient population
                                                              completely assured that the patient and/or caregiver understands them and can follow them. This requires making sure that the patient and/or caregiver received the
                                                              information, understood it, and were given supporting materials that either they, or an appropriate caregiver/family member, understood and would be able to implement
                                                              the medication regimen once leaving the hospital or other setting. These supporting materials must include the name and contact information that a patient and/or
                                                              caregiver can access at any time if they have further questions once they actually attempt to comply with the protocol after leaving a facility. This is particularly crucial for
                                                              patients for whom the medication protocol may be modified depending on the patients progress post-discharge. Without making sure that the measure specifications
                                                              address these concerns, we would not be able to support this measure.



Member       Jill Epstein, Society of     Measure CC-073-09   Provision of a reconciled medication list to the receiving provider(s) at hospital discharge' is an important measure that is missing from the 073/074/075 bundle, and           No action taken. NQF and the Committee recognize this as a
             Hospital Medicine                                should be added.                                                                                                                                                                 first step in addressing measures for care coordination




Member       John Agos, sanofi-adventis   Measure CC-073-09   This measure is well specified and very important. It should also include a requirement to provide educational material to the patient in the appropriate format for their       Developer Response: Consistent with the cited evidence
                                                              level of health literacy.                                                                                                                                                        statements and Joint Commission standards, the measure
                                                                                                                                                                                                                                               documentation states that information should be provided in a
                                                                                                                                                                                                                                               manner that can be understood by patients or their caregivers.


Non-Member   Kay Jewell, Centers for      Measure CC-073-09   This measure is very important if properly done. It is important that the patient not receive multiple lists in the days before discharge or at the time of discharge to avoid Developer Response: Providing educational material on
             Consumers of Healthcare                          confusion and the chance of medication errors. It is also important that the final list of medications and their status is consistent with the medication lists in their transition medications is an important process of care for patients at the
                                                              record AND the prescriptions written AND available at the pharmacy.                                                                                                                 time of discharge, but measuring this process (above and
                                                                                                                                                                                                                                                  beyond the requirements of the reconciled medication list)
                                                              The measure does not include a requirement for educational material on medications to be sent home, especially for new or changed medications. This requirement                     would create an additional and undesirable documentation
                                                              should be added to reinforce its value. Education in the hospital is valuable and necessary, but retention and the ability to recall details are often limited during the           burden.
                                                              transition to home. Educational materials for home use can provide a valuable resource. For some patients receiving new injections, family members or other caregivers
                                                              may also be enlisted to assist with injections/medications. Printed/video material can educate those who are helping the patient but have been unable to be present in the
                                                              hospital for education.

                                                              This is especially important when the patient is going home on new medication like the anticoagulants used in bridge therapy and extended duration of prophylactic
                                                              anticoagulation. Patients can be confused about why they need to take both anticoagulants and concerned they will be overdosing so they stop taking one of the
                                                              anticoagulants before the bridge is complete

Member       Mary Andrawis, American      Measure CC-073-09   The Society applauds this measures emphasis on the importance of reconciling and communicating the medication list upon discharge. However, ASHP believes that                   Developer Response: To decrease the data collection burden
             Society of Health-System                         this list must be differentiated from the medication list contained in the transition record in measures CC-074-09 and CC-075-09. The medication list received by patients       for measure CC-074-09 and to promote compliance, the
             Pharmacists                                      should be in a patient-friendly format that can be kept and carried by the patient, whereas the medication list in the transition record should be more extensive, containing    [PCPI] work group opted for a less stringent set of required
                                                              the pre-admission medication list and complete information about all medications given during the admission, including those that should not be continued after discharge        elements in the ―current medication list‖ than those specified for
                                                              (as described in comments on CC-074-09 and CC-075-09). We suggest that the Numerator Statement asterisk in this measure should also include the route, frequency,                the ―reconciled medication list‖ of measure CC-073-09. The
                                                              and reason for use as required elements (currently only states prescribed dosage, instructions, and intended duration must be included for each continued and new                bundling of measures 1-3 is intended to assure that discharged
                                                              medication listed. A comprehensive medication reconciliation tool developed through multidisciplinary efforts that includes additional elements of a well-designed patient-      patients receiving a transition record will also receive the full
                                                              friendly reconciled medication list is ASHPs My Medicine List. This patent education tool was designed to help stimulate discussions between patients and health care            reconciled medication list.
                                                              professionals. It was developed through an ASHP-convened multidisciplinary Continuity of Care in Medication Use Summit.

Member       Mary Andrawis, American      Measure CC-073-09   ASHP encourages revisions to the language of this measure that would ensure the quality of the patient education provided with the medication list as follows:                Developer Response: Consistent with the cited evidence
             Society of Health-System                         Percentage of patients who received a reconciled medication list AND INSTRUCTIONS PROVIDED AT THE CULTURALLY-APPROPRIATE READING AND                                          statements and Joint Commission standards, the measure
             Pharmacists                                      HEALTH-LITERACY LEVEL. As currently written, the measure can be met simply by the provision of the written list. Provision of a list without explanation misses a             documentation states that information should be provided in a
                                                              significant opportunity to improve patient safety. ASHP policy states that medication reconciliation should be a patient-centered process, taking into account the patients manner that can be understood by patients or their caregivers.
                                                              level of health literacy, cognitive and physical ability, and willingness to engage in his or her personal health care. The goal is improvement in patient well-being through
                                                              education, empowerment, and active involvement in the accurate transfer of medication information throughout transitions along the healthcare continuum. NQFs
                                                              Medication Reconciliation Safe Practice 17 specifications state, When the patient leaves the organizations care, the current list of reconciled medications is provided to
                                                              the patient, and family, as needed, and is explained to the patient and/or family, and the interaction is documented. The list and instructions should be provided at a
                                                              reading and health literacy level that is appropriate for the individual patient.

Member       Nancy Foster, American       Measure CC-073-09   The AHA believes that, as currently specified, this measure holds promise as an important, scientifically valid, and feasible measure. We believe it is appropriate to  No action taken.
             Hospital Association                             exclude patients who expire and patients who leave against medical advice or who discontinue care from this measure population. We suggest that this measure be field-
                                                              tested among a broad group of hospitals, including large and small hospitals and hospitals with various levels of electronic health record implementation, before it is
                                                              implemented in a national program.

Member       Rebecca Zimmermann,          Measure CC-073-09   The AMA PCPI measure specifications indicate that they are undergoing specification for EHR implementation. AHIP eagerly awaits these specifications.                            Comment for which no action can be taken
             AHIP


Non-Member   Renee Demski, Johns          Measure CC-073-09   It would be great to use this opportunity to re-define medication reconciliation to specifically exclude medications that are optional and designed for comfort, such as         Developer Response:Patient safety advocates recommend
             Hopkins Medicine                                 PRN laxatives or acetaminophen, and don't insist on having dose and frequency matching for such medications. Having an all-or-none reconciliation process is absurd              that medication reconciliation should include all medications
                                                              and should be revised to recognize that dose and frequency are very important for some medications (e.g., Warfarin), but not others (e.g., Dulcolax).                            taken by the patient. Further refinement of the documentation
                                                                                                                                                                                                                                               requirements would also add complexity to the measure and
                                                                                                                                                                                                                                               may decrease its use.

Member       Carol Sakala, Childbirth     Measure CC-074-09   We support this measure and welcome inclusion of the specification of documentation that the patient or caregiver who received the discharge record was given a                  Comment supports draft report
             Connection                                       review of the relevant information.


Member       Christine Chen, Pacific      Measure CC-074-09   Transition Record Received by Discharged Patients (CC-074-09): We support this measure in and are pleased to see that a component of the specifications is a                     Comment supports draft report
             Business Group on Health                         requirement that documentation be made that the patient or caregiver who received the discharge record was provided a review of all the information.




                                                                                                                            NQF DRAFT: DO NOT CITE, QUOTE, REPRODUCE, OR CIRCULATE                                                                                                                                  8
Member       Barbara Rudolph, The         General             The Leapfrog Group supports the National Quality Forum's efforts to address the lack of care coordination evident in our current healthcare delivery environment. The      Comment for which no action can be taken. NQF recognizes
             Leapfrog Group                                   Leapfrog Group also supports the effort to develop a comprehensive framework for care coordination measurement. However, the devil is in the details, in particular, the the importance of outcome measures and other NQF projects
                                                              use of terminology that is limiting in terms of application of these metrics. We hope that the National Quality Forum would broaden these preferred practices to all       are currently addressing this issue
                                                              licensed healthcare providers who are delivering "primary care" to patients. In addition, we hope that NQF will quickly address the need for linkage of these practices to
                                                              the outcomes of care. We would like NQF to avoid the same journey through process measures that has occurred with hospital and physician measures.


Member       Debra Ness, National      Measure CC-074-09      We support this measure because it specifically requires that documentation be made that the patient or caregiver who received the discharge record was provided a                Comment supports draft report
             Partnership for Women and                        review of all the information.
             Families



Member       Gayle Fortner, HC21          Measure CC-074-09   I support this measure in and are pleased to see that a component of the specifications is a requirement that documentation be made that the patient or caregiver who             Comment supports draft report
                                                              received the discharge record was provided a review of all the information.


Member       Janet Leiker, American    Measure CC-074-09      For this measure to be of more value, would suggest that a an actual follow-up appointment be scheduled within one week.                                                The bundling of measures 1-3 is intended to assure that
             Academy of Family                                                                                                                                                                                                        discharged patients receiving a transition record will also
             Physicians. Commission on                                                                                                                                                                                                receive the full reconciled medication list. Further inclusions in
             Quality and Practice                                                                                                                                                                                                     the measure specifications are possible as the measure is
                                                                                                                                                                                                                                      tested and evolves.
Member       John Agos, sanofi-adventis   Measure CC-074-09   We would suggest the addition of 2 elements: The record should also include secondary diagnoses which the patient is being treated for at the time of discharge, both   Developer Response: Patient safety advocates recommend
                                                              acute and chronic conditions. The element for education should be emphasized. At the very least, the patient with AF needs specific instructions in the appropriate     that medication reconciliation should include all medications
                                                              format for the patient (written, pictorial or DVD documentation) on how to recognize symptoms, when to contact their physician and when to present to the ED. Many will taken by the patient. Further refinement of the documentation
                                                              also be on anticoagulation and need specific instructions and contact information for monitoring and managing problems prior to their first clinic visit.               requirements would also add complexity to the measure and
                                                                                                                                                                                                                                      may decrease its use.


Non-Member   Kay Jewell, Centers for      Measure CC-074-09   We endorse this measure but believe the patient should receive information about secondary conditions as well. This serves two purposes. It provides the patient with             Developer Response: Although the inclusion of secondary
             Consumers of Healthcare                          important information about their hospital stay. The patient may be aware of having experienced problems, but may not recall important details, especially if they were           diagnoses in the transition record is desirable, the additional
                                                              very sick. They may recall being tested for conditions or even being treated for them but they may not be clear about whether it was determined they had the condition or         requirement would add to the documentation burden for the
                                                              what the medical terms are for the conditions they experienced. If the diagnoses that were active during the admission are not included on the summary, the patient can           measure and may decrease its use.
                                                              easily be confused about what happened, whether they actually had something and why they are taking medication. This document also helps educate the patient about
                                                              what conditions they did have so that when they are asked in the future for their history, they can provide more accurate information.


Non-Member   Kay Jewell, Centers for      Measure CC-074-09   An example of a condition for which this is important is deep vein thrombosis and pulmonary emboli.                                                                               Comment for which no action can be taken
             Consumers of Healthcare
                                                              The same information that is on the medication list should be on the transition record. If there is any change in the medication because of issues with the pharmacy
                                                              orders at discharge, this should be recorded so the patient understands why the papers list one medication, dose or schedule of use and the bottle from the pharmacy
                                                              says something different.

                                                              The patient is no better educated and prepared for self-management if they have multiple lists and papers that contain different information. Advance discharge material
                                                              printed and used with education 2 days before discharge should be reconciled with the material provided the morning of discharge and the time of discharge.

Member       Mary Andrawis, American      Measure CC-074-09   These comments are the result of personal family experience as well as record. However, ASHP believes thatdiscahrge.
                                                              ASHP supports the medication list as a critical element of the transition communication with other patients at the transition records medication list should be                   Developer Response: Consistent with the cited evidence
             Society of Health-System                         differentiated from the medication list described in CC-073-09 and should contain the pre-admission medication list and complete information about all medications                statements and Joint Commission standards, the measure
             Pharmacists                                      given during the admission, including those that should not be continued after discharge. In the Numerator Statement, the Society suggests changing the verbiage current          documentation states that information should be provided in a
                                                              medication list to read Pre-admission medication list, all medications given during the inpatient stay, and reconciled medication list. The asterisked numerator element          manner that can be understood by patients or their caregivers.
                                                              definition should include the same verbiage to described the reconciled medication list as used in CC-073-09 to provide consistency as well as other medication                   To decrease the data collection for measure # CC-074-09 and
                                                              information that might be available from the medication administration record and from the pharmacy information system. ASHP encourages revisions to the language                 to promote compliance, the [PCPI] work group opted for a less
                                                              that would ensure the quality of the patient education provided with the transition record as follows: Percentage of patients who received a written transition record AND        stringent set of required elements in the ―current medication list‖
                                                              INSTRUCTIONS PROVIDED AT THE CULTURALLY-APPROPRIATE READING AND HEALTH-LITERACY LEVEL As currently written, the measure can be met                                                than those specified for the ―reconciled medication list‖ of
                                                              simply by the provision of the transition record. Provision of the record without explanation misses a significant opportunity to improve patient safety.                         measure CC-073-09. The bundling of measures 1-3 is intended
                                                                                                                                                                                                                                                to assure that discharged patients receiving a transition record
                                                                                                                                                                                                                                                will also receive the full reconciled medication list.



Member       Nancy Foster, American       Measure CC-074-09   The AHA believes that, as currently specified, this measure holds promise as an important, scientifically valid, and feasible measure. We believe it is appropriate to            No action taken. The measure is recommended for time-
             Hospital Association                             exclude patients who expire and patients who leave against medical advice or who discontinue care from this measure population. We suggest that this measure be field-            limited endorsement, which requires additional testing, which
                                                              tested among a broad group of hospitals, including large and small hospitals and hospitals with various levels of electronic health record implementation, before it is           includes field testing.
                                                              implemented in a national program.
Member       Barbara Rudolph, The         Measure CC-075-09   The Leapfrog Group is supportive of this measure--particularly the time frame of 24 hours. Often, readmissions occur because of a lack of information being provided to           Comment supports draft report
             Leapfrog Group                                   the primary care caregivers in a timely manner. A confirmation of receipt is also critical.
Member       Belinda Ireland, BJC         Measure CC-075-09   This measure begins to address an essential component of care coordination - timely communication between care providers. In the absence of real-time access by all               Developer Response: The intent of measures 074-075 is to
             Healthcare                                       providers of a patient's full medical records and real-time notification of patient change in status, this measure is a reasonable first attempt to improve notification. We      standardize a minimum set of information that patients should
                                                              recommend that the measure developers consider modification of the numerator statement to include transmission of the actual relevant inpatient records (discharge                receive at the time of discharge (in a "transition record") and
                                                              summary, medication records, etc) to reduce error from transferring this information to yet another document (the "transition record").                                           that will also be transmitted to the next provider of care in a
                                                                                                                                                                                                                                                timely fashion. Transmission of additional information may be
                                                                                                                                                                                                                                                appropriate and desirable, but is beyond the scope of these
                                                                                                                                                                                                                                                measures.

Member       Carol Sakala, Childbirth     Measure CC-075-09   We are very supportive of this measure, as ensuring that the patient's primary care provider receives an impatient discharge transition record is an essential component          Comment supports draft report
             Connection                                       of improved care coordination.

Member       Christine Chen, Pacific      Measure CC-075-09   Timely Transmission of Transition Record to Home/Selfcare or Any Other Site of Care (CC-075-09): We are very supportive of this measure, and believe that                         Comment supports draft report
             Business Group on Health                         measuring whether an inpatient discharge transition record is sent to the patients primary care provider is a crucial step toward improving care coordination.


Member       Debra Ness, National      Measure CC-075-09      We are very supportive of this measure, and believe that measuring whether an inpatient discharge transition record is sent to the patients primary care provider is a       Comment supports draft report
             Partnership for Women and                        crucial step toward improving care coordination. This should obviously be standard of practice, but since it is not, it is a foundational metric of a coordinated system and
             Families                                         should be included in this portfolio.
Member       Gayle Fortner, HC21          Measure CC-075-09   I am very supportive of this measure, and believe that measuring whether an inpatient discharge transition record is sent to the patients primary care provider is a crucial Comment supports draft report
                                                              step toward improving care coordination.
Member       Janet Leiker, American    Measure CC-075-09      There needs to be an acknowledgement of the transfer of responsibility of care.                                                                                              Developer Response: The [PCPI] work group chose to limit
             Academy of Family                                                                                                                                                                                                             this measure to the accountability of the discharging facility for
             Physicians. Commission on                                                                                                                                                                                                     timely transmission of the transition record; the accountability
             Quality and Practice                                                                                                                                                                                                          of the receiving facility may be a focus of a future phase of
                                                                                                                                                                                                                                           PCPI work on care transitions/ care coordination.

Member       John Agos, sanofi-adventis   Measure CC-075-09   There are 4 elements that would increase the value of the transition record: detailed information about decision making and patient education, specific information about         Developer Response: Additional required elements were
                                                              which of the specialties are to be contacted for which problem/medication if the patient has multiple conditions involving multiple specialties, and be sure that the patient     considered for the transition record, but the [PCPI] work group
                                                              actually has an appointment within 7-10 days, and that it is arranged so that the patient has transportation and is able to make the date and time selected. We support           did not wish to create an excessive documentation burden.
                                                              this measure but suggest it is missing specific information about patient education that should be specified in the measure for all patients but especially patients with AF.     Patient understanding of discharge instuctions is the focus of
                                                              Newly diagnosed patients need specific instructions about new medication, how to handle symptoms/arrhythmias and anticoagulation changes, especially if it is new.                other ongoing efforts, including recent enhancements to the
                                                              The receiving team needs to know what level of education the patient has received and what to expect of them for self management during the time between discharge                HCAHPS survey, and may be the subject of future measures
                                                              and the first visit.                                                                                                                                                              development efforts.

Non-Member   Kay Jewell, Centers for      Measure CC-075-09   The Discharge Summary is intended to inform the receiving team about what happened during the hospital stay. It should include information about decision-making,           Developer Response: Several transition record requirements
             Consumers of Healthcare                          special issues, and conditions that require immediate attention at the time of discharge. Health literacy issues and the education received and still needed should be      are listed under the heading of "Contact information/ Plan for
                                                              included. Final instructions should be included.                                                                                                                            follow-up care" and were considered by the [PCPI] work group
                                                                                                                                                                                                                                          to be sufficient to guide/assist the patient in addressing post-
                                                              Transition issues would especially apply to conditions that require prolonged treatment at the time of discharge, e.g. completion of a course of antibiotics or prophylaxis discharge questions or problems.
                                                              for VTE or anticoagulation treatment for VTE. Hospitalists are hesitant to prescribe treatment to be continued because of concerns about liability for errors and adverse
                                                              events, e.g. high alert medications and medications known to be associated with errors, ED visits and readmissions. The link to the primary care after discharge is
                                                              important to alleviate these concerns. Face-to-face with the primary care physician will reinforce the need to continue anticoagulants, provide an opportunity to answer
                                                              questions and concerns which have arisen since discharge, and perform blood testing/monitoring and dose adjustment.

                                                              The discharge plan for the patient should also specify which specialties are to be contacted for which problem/medication if the patient has multiple conditions and
Member       Mary Andrawis, American      Measure CC-075-09   multiple specialists. medication list as a critical element of the transition record as described in CC-074-09 and strongly recommends that all elements of the transition
                                                              ASHP supports the                                                                                                                                                                 Developer Response: To decrease the data collection burden
             Society of Health-System                         record, including the medication list, be consistent between these two measures. The transition records medication list should be differentiated from the medication list         for measure CC-074-09 and to promote compliance, the
             Pharmacists                                      described in CC-073-09 and should contain the pre-admission medication list and complete information about all medications given during the admission, including those            [PCPI] work group opted for a less stringent set of required
                                                              that should not be continued after discharge. In the Numerator Statement, the Society suggests changing the verbiage current medication list to read Pre-admission                elements in the ―current medication list‖ than those specified for
                                                              medication list, all medications given during the inpatient stay, and reconciled medication list. The asterisked numerator element definition should include the same             the ―reconciled medication list‖ of measure CC-073-09. The
                                                              verbiage to described the reconciled medication list as used in CC-073-09 to provide consistency as well as other medication information that might be available from             bundling of measures 1-3 is intended to assure that discharged
                                                              the medication administration record and from the pharmacy information system. As a future enhancement to this measure or an area for future measure development,                 patients receiving a transition record will also receive the full
                                                              the patients outpatient pharmacy should also have access to the transition record to provide continued care in medication management when the IT infrastructure is                reconciled medication list.
                                                              available.

Member       Nancy Foster, American       Measure CC-075-09   The AHA believes that, as currently specified, this measure holds promise as an important, scientifically valid, and feasible measure. We believe it is appropriate to  No action taken. The measure is recommended for time-
             Hospital Association                             exclude patients who expire and patients who leave against medical advice or who discontinue care from this measure population. We suggest that this measure be field- limited endorsement, which requires additional testing, which
                                                              tested among a broad group of hospitals, including large and small hospitals and hospitals with various levels of electronic health record implementation, before it is includes field testing.
                                                              implemented in a national program.

Member       Angela Franklin, American    Measure CC-076-09   ACEP appreciates the work of the Steering Committee on these measures; however we do note that given the current state of health IT adoption and functionality in the             Developer Response: The required elements of the transition
             College of Emergency                             ED, which is often not within the control of the emergency physician, these measures will present significant documentation challenges. The measure defines the                   record to be completed at the time of ED discharge (including
             Physicians                                       transition record (for ED discharges) as follows: a core, standardized set of data elements related to patients diagnosis, treatment, and care plan that is discussed with        "major tests and procedures"), as well as the numerator
                                                              and provided to patient in written, printed, or electronic format. Electronic format may be provided only if acceptable to patient. ACEP recommends that the definition be        element definitions and denominator exclusions, were
                                                              expanded to allow the transition record to also be transmitted automatically by fax to the follow-up caregiver, and that the caregiver receiving the transition record may        developed in close collaboration with emergency physicians.
                                                              include the follow up care provider including the primary physician, other healthcare professional, or site designated for followup care if known. ACEP recommends                Several pilot/testing projects are in development for these
                                                              clarification regarding: Whether major procedures and tests performed during the ED visit must be listed and/or the results included on the transition record, and                measures; the [PCPI] work group may consider modifications
                                                              Whether, if no major procedures and tests were performed during the ED visit, this must be still must be reported, e.g.: no major procedures and tests were performed.            needed after results from initial testing are made available.



Member       Angela Franklin, American    Measure CC-076-09   ACEP would recommend against an approach that would require detailed documentation regarding major procedures and tests on what we believe is intended to be a                    Developer Response: The required elements of the transition
             College of Emergency                             streamlined, patient readable transition record that is not unduly burdensome for the ED to generate. ACEP notes that access to a follow-up care professional is limited          record to be completed at the time of ED discharge (including
             Physicians                                       for many ED patients. The measure definition (b) addresses this in part: If no physician, other healthcare professional, or site designated or available, patient may be          "major tests and procedures"), as well as the numerator
                                                              provided with information on alternatives for obtaining follow-up care needed, which may include a list of community health services/other resources. In light of the             element definitions and denominator exclusions, were
                                                              continuing problem of access however, ACEP also recommends these additions to the denominator exclusions: Lack of provider availability, Patients from out of area,               developed in close collaboration with emergency physicians.
                                                              Patients whose follow up physician cannot be identified, and                                                                                                                      Several pilot/testing projects are in development for these
                                                              Patients who left without being seen or screened.                                                                                                                                 measures; the [PCPI] work group may consider modifications
                                                                                                                                                                                                                                                needed after results from initial testing are made available.


Member       Janet Leiker, American    Measure CC-076-09      Communication with the primary care physician is essential and should be included.                                                                                                Developer Response: Given concerns about documentation
             Academy of Family                                                                                                                                                                                                                  burden at the time of ED discharge, the [PCPI] work group
             Physicians. Commission on                                                                                                                                                                                                          chose to limit the requirements of this measure to the elements
             Quality and Practice                                                                                                                                                                                                               of the transition record and to not require direct communication
                                                                                                                                                                                                                                                with other providers of care.

Member       Mary Andrawis, American      Measure CC-076-09   ASHP suggests being consistent with the approach used for the inpatient setting by adding a separate measure to assess the percentage of patients who receive a                   Developer Response: The elements of this measure related to
             Society of Health-System                         reconciled medication list at the time of discharge from the E.D. If no medication changes are made during the E.D. visit, patients should be excluded from the                   medications ("list of new medications and changes to
             Pharmacists                                      denominator per Joint Commission NPSG 8. Although the challenging environment of the E.D. may result in a lower compliance rate compared to the inpatient setting,                continued medication…") were tailored specifically for the ED
                                                              the provision of a reconciled medication list if any changes are made in the E.D. offers critical potential to improve care. ASHP encourages revisions to the language            discharge and were developed in collaboration with ED
                                                              that would ensure the quality of the patient education provided with the transition record as follows: Percentage of patients who received a written transition record AND        physicians. The transition record definition used for this
                                                              INSTRUCTIONS PROVIDED AT THE CULTURALLY-APPROPRIATE READING AND HEALTH-LITERACY LEVEL as currently written, the measure can be met                                                measure does include the requirement that the transition record
                                                              simply by the provision of the transition record. Provision of the record without explanation is incomplete. This is recognized in the definition of a transition record in CC-   be "discussed with and provided to patient," as suggested.
                                                              075-09 care plan that is discussed with and provided to patient. This is also mentioned in the Measure Importance section, Opportunity for Improvement, where it is
                                                              stated that studies have documented gaps in the provision or explanation of emergency department discharge instructions


Member       Nancy Foster, American       Measure CC-076-09   The AHA believes that, as currently specified, this measure holds promise as an important, scientifically valid, and feasible measure. We suggest that this measure be        Plans for field testing the full set of Care Transitions measures
             Hospital Association                             field-tested among a broad group of hospitals, including large and small hospitals and hospitals with various levels of electronic health record implementation, before it is are in development.
                                                              implemented in a national program.




                                                                                                                            NQF DRAFT: DO NOT CITE, QUOTE, REPRODUCE, OR CIRCULATE                                                                                                                                    9
Member       Barbara Rudolph, The        General             The Leapfrog Group supports the National Quality Forum's efforts to address the lack of care coordination evident in our current healthcare delivery environment. The      Comment for which no action can be taken. NQF recognizes
             Leapfrog Group                                  Leapfrog Group also supports the effort to develop a comprehensive framework for care coordination measurement. However, the devil is in the details, in particular, the the importance of outcome measures and other NQF projects
                                                             use of terminology that is limiting in terms of application of these metrics. We hope that the National Quality Forum would broaden these preferred practices to all       are currently addressing this issue
                                                             licensed healthcare providers who are delivering "primary care" to patients. In addition, we hope that NQF will quickly address the need for linkage of these practices to
                                                             the outcomes of care. We would like NQF to avoid the same journey through process measures that has occurred with hospital and physician measures.


Member       Phelan Michael, Cleveland   Measure CC-076-09    We would vote against the measure as written. Needs further work and explanation of what they are trying to measure with this metric.                                        Developer Response: The measure does require that the ED
             Clinic                                          Are we trying to define the elements of an ideal dc from the ed? If so what are the elements we think are important? It seems this metric has defined them with little        transition record include all of the elements specified for the
                                                             research or evidence to support this.                                                                                                                                         numerator.

                                                             Dc diagnosis                                                                                                                                                                  The documentation requirements selected for this measure are
                                                             Follow-up recommendation                                                                                                                                                      consistent with the quality improvement objectives and specific
                                                             New medication or changes to old medications                                                                                                                                  quality indicators published recently by an SAEM task force.
                                                             Dc instructions.                                                                                                                                                              (Terrell KM, et al. Acad Emerg Med 2009;16:441-449)
                                                                                                                                                                                                                                           The required elements of the transition record to be completed
                                                             So far seem to be boilerplate on most dc instructions however one of the elements may prove to be cumbersome?                                                                 at the time of ED discharge (including "major tests and
                                                             Results of relevant testing/Explanation of studies performed? Does anyone do this currently? How will this be measured. If the dc instructions say hypokalemia/low            procedures"), as well as the numerator element definitions and
                                                             potassium will this be able to be counted 2x once for dc instruction once for pertinent testing?                                                                              denominator exclusions, were developed in close collaboration
                                                             We typically obtain xrays and only have preliminary reads.                                                                                                                    with emergency physicians. Several pilot/testing projects are in
                                                                                                                                                                                                                                           development for these measures; the [PCPI] work group may
                                                             Are these the elements we going to define as the ideal dc template? If so I would like to see some supplemental information data that it improves the outcome we are          consider modifications needed after results from initial testing
                                                             seeking.                                                                                                                                                                      are made available.
                                                             Further more if accepted what should we measure will it be a composite score? Or if you fail one you will fail the measure? 3/5 pass?
                                                             (continued)


Member       Phelan Michael, Cleveland   Measure CC-076-09   We are unsure what exactly this measure is attempting to do. Increase the number of pages of dc instructions or be sure we have clear dc instructions, a dc diagnsosis ,      Developer Response: The measure does require that the ED
             Clinic                                          approriate fu instrcutions? The data is clear that some pt may not understand their dc instructions or results of their test but does this help?                              transition record include all of the elements specified for the
                                                                                                                                                                                                                                           numerator.
                                                             This part of the ed care needs further study before burdening ED's. What effect does including all this have on the outcome or care of the patient? What exactly should a
                                                             dc instruction have, what currently is happening? Is there a current gold standard? If not develop one or have a large emergency medicine organization(ACEP/SAEM)             The documentation requirements selected for this measure are
                                                             develop one.Do not foist "standardized" dc instruction on an already burdened system without fully vetting the consequences. Does ACEP or SAEM have a policy or               consistent with the quality improvement objectives and specific
                                                             guideline on dc instructions? Is it evidence based or consensus? Before accepting more we would like to see a white paper defining the scope and exact problem they           quality indicators published recently by an SAEM task force.
                                                             are trying to address here. if we are tryijg to be evidence based? is the problem with what within the dc instrcutions or the manner in whcih it is conveyed? mnay ed pt do   (Terrell KM, et al. Acad Emerg Med 2009;16:441-449)
                                                             not have primary care gphsycioans and utilze the ed for this.                                                                                                                 The required elements of the transition record to be completed
                                                                                                                                                                                                                                           at the time of ED discharge (including "major tests and
                                                                                                                                                                                                                                           procedures"), as well as the numerator element definitions and
                                                                                                                                                                                                                                           denominator exclusions, were developed in close collaboration
                                                                                                                                                                                                                                           with emergency physicians. Several pilot/testing projects are in
                                                                                                                                                                                                                                           development for these measures; the [PCPI] work group may
                                                                                                                                                                                                                                           consider modifications needed after results from initial testing
                                                                                                                                                                                                                                           are made available.




Member       Phelan Michael, Cleveland   Measure CC-076-09   we would recommend against an approach that would require detailed documentation regarding major procedures and tests on what we believe is intended to be a                  Developer Response: The documentation requirements
             Clinic                                          streamlined, patient readable transition record that is not unduly burdensome for the ED to generate                                                                          selected for this measure are consistent with the quality
                                                                                                                                                                                                                                           improvement objectives and specific quality indicators
                                                                                                                                                                                                                                           published recently by an SAEM task force. (Terrell KM, et al.
                                                                                                                                                                                                                                           Acad Emerg Med 2009;16:441-449)

Non-Member   Renee Demski, Johns         Measure CC-076-09   CC-050-09 and CC-076-09 are not reflective of the quality of ED care delivery                                                                                                 No action taken. Measure CC-050-09 is not reflective of quality
             Hopkins Medicine                                                                                                                                                                                                              care services in the ED, it's reflective of care coordination.
                                                                                                                                                                                                                                           Regarding Measure CC-076-09, the Committee felt that ED
                                                                                                                                                                                                                                           discharge was important to care coordination.

Non-Member   Renee Demski, Johns         Measure CC-078-09   While patients may receive care from a Melanoma surgeon at Johns Hopkins Hospital, they often receive follow up care in other settings with other providers. This             Developer Response: A biopsy log is essentially a registry.
             Hopkins Medicine                                measure does not necessarily indicate appropriate follow-up or care coordination.                                                                                             Ideally, such a log would be incorporated into routine
                                                                                                                                                                                                                                           processes and would be generated automatically from
                                                                                                                                                                                                                                           electronic records whenever a biopsy is performed. If an
                                                                                                                                                                                                                                           automatic log is not created it should be maintained in some
                                                                                                                                                                                                                                           other fashion, either electronic or, if necessary, on paper. The
                                                                                                                                                                                                                                           measure involves one key aspect of care delivery required
                                                                                                                                                                                                                                           (ensuring an annual follow up exam is scheduled) for a high-risk
                                                                                                                                                                                                                                           population . This measure represents a first step in helping
                                                                                                                                                                                                                                           ensure that the scheduling of the yearly follow up exam occurs
                                                                                                                                                                                                                                           and we hope in the future as health care systems become more
                                                                                                                                                                                                                                           capable of sharing information it can be expanded beyond one
                                                                                                                                                                                                                                           setting of care. We have applied to AMA for CPTII codes that
                                                                                                                                                                                                                                           would also allow this measure to be coded from outpatient
                                                                                                                                                                                                                                           claims data. Code A:biopsy performed and entered into
                                                                                                                                                                                                                                           tracking log; code B1: biopsy results reviewed, entered into
                                                                                                                                                                                                                                           tracking log and communicated to patient or patient's
                                                                                                                                                                                                                                           guardian/caregiver and to Patient's PCP and/or other
                                                                                                                                                                                                                                           physician/professional responsible for follow-up care; code B2:
                                                                                                                                                                                                                                           biopsy results reviewed, entered into tracking log and
                                                                                                                                                                                                                                           communicated to patient or patient's guardian/caregiver
                                                                                                                                                                                                                                           (patient does not wish results to be communicated to PCP or
                                                                                                                                                                                                                                           patient does not have a PCP and there is no other
                                                                                                                                                                                                                                           physician/professional responsible for follow-up care).


Member       Janet Leiker, American    Measure CC-078-09     It should be more clearly stated that the follow-up exam can be performed by the primary care physician or the physician who diagnosed the melanoma.                          Developer Response: This measure was developed with the
             Academy of Family                                                                                                                                                                                                             intention that the physician, within his/her practice, has a
             Physicians. Commission on                                                                                                                                                                                                     system in place to identify when patients are needed for their
             Quality and Practice                                                                                                                                                                                                          annual follow up exam. The measure was intentionally left open
                                                                                                                                                                                                                                           to allow any physician who treats patients with a diagnosis of
                                                                                                                                                                                                                                           melanoma, regardless if it is a primary care physician or a
                                                                                                                                                                                                                                           specialist. to use the measure within their practice. It is the
                                                                                                                                                                                                                                           intent of all PCPI measures to be used by the physician who is
                                                                                                                                                                                                                                           caring for the patient with the diagnosis. This is made clear in
                                                                                                                                                                                                                                           the documentation of the full AAD/PCPI/NCQA Melanoma
                                                                                                                                                                                                                                           measurement set. For this measure, we are happy to work with
                                                                                                                                                                                                                                           NQF to make sure that the intention of the measure is clear.


Member       Belinda Ireland, BJC        Measure 0228        This measure was missing its measure submission form, and could therefore not be accurately evaluated for comment. We recommend you provide the necessary                     Follow-up conducted to direct individual to documents
             Healthcare                                      information and extend comment period for this measure.
Member       Lee Anne Gardner,           Measure 0228        This measure, 3-Item Care Transitions Measures, has been previously endorsed by the NQF and is being reviewed for continued endorsement. We can not find the                  Follow-up conducted to direct individual to documents
             American College of                             measure submission form with data to support continued endorsement. Can this information be shared to inform our deliberations?
             Physicians, Performance
             Measurement
Member       Carol Sakala, Childbirth    Measures Not        We ask that the care coordination team reconsider inclusion of "Timely case management assessment rates for pregnant women at high risk in managed care (CC-018-              Committee recommended advancement if the following
             Connection                  Recommended         09)." The size of the relevant population, associated costs, documented new-onset postpartum morbidities, vulnerable window of impact for both women and                      conditions could be met: (1) specify aspects of care
                                                             fetuses/newborns, documented opportunities for quality improvement, and inherent care coordination challenges across maternity and other health care settings and             coordination to occur during the initial assessment, (2) define
                                                             providers in this clinical area together justify a high-quality focused measure for care coordination of pregnant women with high-risk pregnancies.                           the process of care plan developement during the assessment
                                                                                                                                                                                                                                           and how the care plan will be shared with relevent providers, (3)
                                                                                                                                                                                                                                           specify criteria for referrals (triggers) to case management for
                                                                                                                                                                                                                                           this population with supporting evidence, (4) provide evidence
                                                                                                                                                                                                                                           to support the 15-day timeframe. The measure developer could
                                                                                                                                                                                                                                           not meet the requirements, but would take these considerations
                                                                                                                                                                                                                                           and provide updates to the measure as it evolves.


Member       Christine Chen, Pacific     Measures Not        Timely Case Management Assessment Rates for Pregnant Women at High Risk in Managed Care (CC-018-09): We ask that this measure be reconsidered for                             Committee recommended advancement if the following
             Business Group on Health    Recommended         endorsement recommendation. The clinical costs of caring for perinatal and post-partum care for both women and pre-term infants should be sufficient cause for                conditions could be met (1) specify aspects of care
                                                             reconsidering this measure, which would provide critical information on how well a health plan is providing care coordination for pregnant women with high risk               coordination to occur during the initial assessment, (2) define
                                                             pregnancies.                                                                                                                                                                  the process of care plan developement during the assessment
                                                                                                                                                                                                                                           and how the care plan will be shared with relevent providers, (3)
                                                                                                                                                                                                                                           specify criteria for referrals (triggers) to case management for
                                                                                                                                                                                                                                           this population with supporting evidence, (4) provide evidence
                                                                                                                                                                                                                                           to support the 15-day timeframe. The measure developer could
                                                                                                                                                                                                                                           not meet the requirements, but would take these considerations
                                                                                                                                                                                                                                           and provide updates to the measure as it evolves.


Member       Debra Ness, National      Measures Not          Timely Case Management Assessment Rates for Pregnant Women at High Risk in Managed Care (CC-018-09): We ask that this measure be reconsidered for                             Committee recommended advancement if the following
             Partnership for Women and Recommended           endorsement recommendation. The clinical costs of caring for perinatal and post-partum care for both women and pre-term infants should be sufficient cause for                conditions could be met: (1) specify aspects of care
             Families                                        reconsidering this measure, which would provide critical information on how well a health plan is providing carecoordination for pregnant women with high risk                coordination to occur during the initial assessment, (2) define
                                                             pregnancies.                                                                                                                                                                  the process of care plan developement during the assessment
                                                                                                                                                                                                                                           and how the care plan will be shared with relevent providers, (3)
                                                                                                                                                                                                                                           specify criteria for referrals (triggers) to case management for
                                                                                                                                                                                                                                           this population with supporting evidence, (4) provide evidence
                                                                                                                                                                                                                                           to support the 15-day timeframe. The measure developer could
                                                                                                                                                                                                                                           not meet the requirements, but would take these considerations
                                                                                                                                                                                                                                           and provide updates to the measure as it evolves.


Member       Gayle Fortner, HC21         Measures Not        Timely Case Management Assessment Rates for Pregnant Women at High Risk in Managed Care (CC-018-09): I ask that this measure be reconsidered for                              Committee recommended advancement if the following
                                         Recommended         endorsement recommendation. The clinical costs of caring for perinatal and post-partum care for both women and pre-term infants should be sufficient cause for                conditions could be met: (1) specify aspects of care
                                                             reconsidering this measure, which would provide critical information on how well a health plan is providing care coordination for pregnant women with high risk               coordination to occur during the initial assessment, (2) define
                                                             pregnancies.                                                                                                                                                                  the process of care plan developement during the assessment
                                                                                                                                                                                                                                           and how the care plan will be shared with relevent providers, (3)
                                                                                                                                                                                                                                           specify criteria for referrals (triggers) to case management for
                                                                                                                                                                                                                                           this population with supporting evidence, (4) provide evidence
                                                                                                                                                                                                                                           to support the 15-day timeframe. The measure developer could
                                                                                                                                                                                                                                           not meet the requirements, but would take these considerations
                                                                                                                                                                                                                                           and provide updates to the measure as it evolves.


Member       Laura Blum, The Heart       Measures Not        In their deliberations, the NQF Steering Committee recommended that the below measures, along with a number of other measures, should be evaluated in a subsequent No action taken. NQF is currently identifying a project with the
             Rhythm Society              Recommended         project: CC-026-09 CHF Cardiology Consultation. Patient(s) with heart failure and two or more recent heart failure ER encounters or hospitalizations that had cardiology appropriate expertise to evaluate these measures
                                                             consultation in the last 24 reported months. CC-027-09 Atrial Fibrillation Cardiology Consultation. Patient(s) with atrial fibrillation and evidence of problematic atrial
                                                             fibrillation control that had cardiology consultation in last 12 reported months. The Heart Rhythm Society respects the Steering Committees determination that these
                                                             measures are not in the immediate scope of the project. However, these consultation measures are important indicators of the quality of patient care. The Heart Rhythm
                                                             Society urges the National Quality Forum to address these measures as soon as possible. Although the first phase of the proposed measure collection for Patient
                                                             Outcomes Project is complete, is the Patient Outcomes Steering Committee able to consider these measures as part of this current project?




Member       Michelle Beauchesne,        Measures Not        The proposed performance measures should include reference to the role of the family and youth, when appropriate, in working within the healthcare home and informing No action taken. The committee recognizes that the measures
             National Association of     Recommended         the management, development, and coordination of care plans. Only three of these recommended measures can be used in pediatrics, and all of these measures are             are a first step for addressing care coordination
             Pediatric Nurse                                 generic (e.g., timely transfer of records). Care coordination, timing, and other functionalities that are being managed through a continuum require information systems
             Practitioners (NAPNAP)                          that can manage temporal reasoning of a variety of types (a computer engineering research area). For any computer system incorporate the processes envisioned in
                                                             this section, it is imperative that every computer system that is participating interactively in the medical home have complete support of automated date/time stamping of
                                                             every piece of information planned for the tracking and a coordination matrix. Also necessary is support for sequential same things in the computerized coding (also a
                                                             form of computerized temporal logic), because multiple instances of the same thing in a single day or week are common in some situations. Medication lists for infants
                                                             and children may or may not be able to be transmitted, depending on whether the specific system supports weight based dosing (an imperative for infants and children).




                                                                                                                          NQF DRAFT: DO NOT CITE, QUOTE, REPRODUCE, OR CIRCULATE                                                                                                                               10
Member       Barbara Rudolph, The         General        The Leapfrog Group supports the National Quality Forum's efforts to address the lack of care coordination evident in our current healthcare delivery environment. The      Comment for which no action can be taken. NQF recognizes
             Leapfrog Group                              Leapfrog Group also supports the effort to develop a comprehensive framework for care coordination measurement. However, the devil is in the details, in particular, the the importance of outcome measures and other NQF projects
                                                         use of terminology that is limiting in terms of application of these metrics. We hope that the National Quality Forum would broaden these preferred practices to all       are currently addressing this issue
                                                         licensed healthcare providers who are delivering "primary care" to patients. In addition, we hope that NQF will quickly address the need for linkage of these practices to
                                                         the outcomes of care. We would like NQF to avoid the same journey through process measures that has occurred with hospital and physician measures.


Member       Michelle Beauchesne,         Measures Not   In the documents discussion of measures not included, NAPNAP along with the AAP agree with the reasons for excluding measures on neonatal intensive care unit                    Comment for which no action can be taken
             National Association of      Recommended    (NICU) admissions as an adverse outcome of prenatal care situations for purposes of this document. It also is possible that the babies admitted to a NICU might have
             Pediatric Nurse                             died prenatally, so having a baby survive to NICU admission at 28 weeks (when intact survival is about 80-85%), may be considered an outstanding success in some
             Practitioners (NAPNAP)                      individual perinatal care situations. However, discharged infants from NICUs are at very high risk for having many care coordination problems, including lack of follow-up
                                                         for potentially permanently disabling conditions (e.g., blindness from retinopathy of prematurity, failure to connect with audio/visual, orthopedic follow up, rehabilitation or
                                                         genetic services). These former NICU infants need special consideration in the care transfer/continuity effort. They often are lost because many change their names in
                                                         the immediate post-discharge period, or they live across state lines or in a different county from the hospital to which they were transported to.



Member       Shel Lyons, Coalition for    Measures Not   Timely Case Management Assessment Rates for Pregnant Women at High Risk in Managed Care (CC-018-09): We ask that this measure be reconsidered for                                Committee recommended advancement if the following
             Improving Maternity          Recommended    endorsement recommendation. The high costs of caring for perinatal and post-partum care for both high-risk women and pre-term infants should be sufficient cause for             conditions could be met: (1) specify aspects of care
             Services                                    reconsidering this measure. This measure would provide critical information on how well a health plan is providing care coordination for pregnant women with high risk           coordination to occur during the initial assessment, (2) define
                                                         pregnancies.                                                                                                                                                                     the process of care plan developement during the assessment
                                                                                                                                                                                                                                          and how the care plan will be shared with relevent providers, (3)
                                                                                                                                                                                                                                          specify criteria for referrals (triggers) to case management for
                                                                                                                                                                                                                                          this population with supporting evidence, (4) provide evidence
                                                                                                                                                                                                                                          to support the 15-day timeframe. The measure developer could
                                                                                                                                                                                                                                          not meet the requirements, but would take these considerations
                                                                                                                                                                                                                                          and provide updates to the measure as it evolves.



Non-Member   Deborah Gutteridge, MS,      Practice 1     Again, sincere congratulations on the committee's work on this extensive document. I am very supportive of the recommendations regarding Preferred Practices to            Comment for which no action can be taken
             Mentor ABI Network                          include "Healthcare Home, Proactive Plan of care and follow-up, Communications, Information systems, and Transitions." This is a strong portion of the document and I
                                                         do not feel additions are warrented here.
Member       Ellen Schwalentocker,        Practice 1     This practice describes only some elements of a healthcare home important to patients in developing and maintaining a relationship with a healthcare team. Additional      Comment incorporated into report
             NACHRI                                      specifications should include a healthcare team that provides culturally competent care. (AAP Policy Statement, Ensuring Culturally Effective Pediatric Care: Implications
                                                         for Education and Health Policy, Committee on Pediatric Workforce, PEDIATRICS Vol. 114 No. 6 December 2004, pp. 1677-1685). The additional specifications
                                                         describe processes of care such as appointments, e-visits and other forms of communication. It is important that functions, such as providing accessible and timely
                                                         information, advice and direct patient care be recognized.

Non-Member   Lauren Agoratus, Family      Practice 1     Domain # 1 Healthcare Home. Preferred Practice #1 The patient shall be provided the opportunity to select the healthcare home that provides the best and most                    Comment supported current draft, no action necessary
             Voices                                      appropriate opportunities to develop and maintain a relationship with healthcare providers.
                                                         We strongly support the concept of consumer directed/family centered care. This is also in keeping with the Patient Centered Primary Care Collaborative (PCPCC)-
                                                         Medical Home project. We agree with the additional specifications that the patient will have ―timely appointments‖ and the opportunities for ―e-visits‖ as we support the
                                                         utilization of telehealth, which increases healthcare access for some underserved families, particularly rural families and families without access to transportation.



Non-member   Ellen Kurtzman, The George Practice 2       Health home should coordinate all health needs not just medical needs as is described in this practice on page 16, line 292.                                                     Comment incorporated into draft report
             Washington University,                      • The primary measure to monitor the implementation of this practice is adherence to the care plan. In the section, ―opportunity for measurement,‖ reference to
             Department of Nursing                       ―demonstrate the use of care plans…‖ should be replaced with ―demonstrate adherence to care plans
             Education
Member       Ellen Schwalentocker,      Practice 2       The specifications for this practice do not sufficiently recognize diverse and effective ways to provide care coordination. The practice seems to focus on in-office             Clarification provided within draft report. The Committee
             NACHRI                                      appointments while other alternatives may be more efficient and satisfying to patients and their families. Published experiences in both Kaiser Permanente and the VA            intended to make reference to populations who are at high-risk
                                                         have shown how information technology has been effectively applied to increase access, increase care coordination and improve management of chronic conditions all               for care coordination services, such as those with co-
                                                         while reducing the number of in-office visits. It would be useful to define what is meant by low-continuity populations.                                                         morbidities

Non-Member   Jan DeRoche, American        Practice 2     Clearly define the case management role and its qualifications. We recommend including the following language: "health professionals to include RN or SW case                    No action taken. A particular professional is not singled out,
             Case Management                             managers with demonstrated expertise in transitional care. Case management professionals must meet individual state licensure requirements and hold appropriate                  reference is made to the entire healthcare team
             Association                                 certification in clinical case management.
Non-Member   Lauren Agoratus, Family      Practice 2     Preferred Practice #2 Healthcare home or sponsoring organizations shall be the central point for incorporating strategies for continuity of care. We agree with the              Comment supported current draft, no action necessary
             Voices                                      concept of the medical home developed by the American Academy of Pediatrics and collaborate with them on many projects, as well as the previously mentioned
                                                         PCPCC. We support the additional specifications that there should be policies regarding access ―after regular business hours.‖ We also agree with the opportunity for
                                                         outcome measures utilizing available ―registries;‖ in our state we have registries for birth defects/genetic conditions, autism, and immunization.

Member       Mary Naylor, University of   Practice 2      • Health home should coordinate all health needs not just medical needs as is described in this practice on page 16, line 292.                                                  Comment incorporated into draft report
             Pennsylvania School of                      • The primary measure to monitor the implementation of this practice is adherence to the care plan. In the section, ―opportunity for measurement,‖ reference to
             Nursing                                     ―demonstrate the use of care plans…‖ should be replaced with ―demonstrate adherence to care plans…‖

Member       Michelle Beauchesne,         Practice 2     Preferred Practice #2: Healthcare home central point for incorporating strategies for continuity of care: NAPNAP along with the AAP are concerned with the opportunity           statement will be adjusted based on commentor's concerns
             National Association of                     to measure the frequency of the patient visit based on patient-generated appointment requests (lines 217-8). Unless the appointment request is actually transformed into
             Pediatric Nurse                             an appointment, few computer systems are programmed to specifically list the concept of an appointment request, not transformed into a visit. A small piece of new
             Practitioners (NAPNAP)                      software patch will be needed.


Member       Michelle Beauchesne,         Practice 2     NAPNAP along with the AAP also request clarification on the low-continuity populations referenced in lines 322-34. Are these populations within the same medical home Clarification provided within draft report. The committee
             National Association of                     or derived from a different care management model (i.e., retail-based clinics)?                                                                                       intended to make reference to populations who are at high-risk
             Pediatric Nurse                                                                                                                                                                                                   for care coordination services, such as those with co-
             Practitioners (NAPNAP)                                                                                                                                                                                            morbidities


Non-member   Ellen Kurtzman, The George Practice 3       • As written, this practice fails to acknowledge the use of electronic systems for documenting and generating plans of care. Line 331 requires the ―plan of care….written        Comment incorporated into draft report
             Washington University,                      by the healthcare home…‖ As an alternative, it should read: ―plan of care…documented by the healthcare home…‖
             Department of Nursing
             Education



Non-member   Ellen Kurtzman, The George Practice 3       Line 344 – The plan of care should not be limited to merely clinical data but should also include functional, social, caregiver burden, etc.                                     Comment incorporated into draft report
             Washington University,
             Department of Nursing
             Education


Non-member   Ellen Kurtzman, The George Practice 3       Additionally, this practice should specify that the plan of care reflect patient preferences and caregiver needs. In the practice’s example, the database should be broader Comment incorporated into draft report
             Washington University,                      than merely medical providers and include all clinical and non-clinical service providers.
             Department of Nursing
             Education


Member       Ellen Schwalentocker,        Practice 3     Plans of care are developed through partnership between the healthcare team and the patient/family. Although shared decision-making is addressed elsewhere in the         Comment incorporated into draft report
             NACHRI                                      document, the wording of several practices seems to miss an opportunity to strengthen the importance of shared decision-making. The wording plans of care
                                                         established and written by the healthcare home would be more accurate if it read plans of care established and documented by the healthcare team. It should be clear
                                                         that interoperability of information should occur not only within the organization but between other healthcare systems. Young families and children move more frequently
                                                         and change healthcare systems more often than older adults. The ability to transfer information to other systems would be more strongly reinforced by specifying plans
                                                         of care should be created, available and updated electronically using national standardized documents that are computable and enable interoperability within and between
                                                         healthcare systems. Specifications under this practice leave out critical elements of plans of care for children. Plans of care should include functional, social and
                                                         caregiver information. We are pleased to see the reference to some pediatric issues in what should be documented in the care play; however, we agree with the AAP
                                                         and NAPNAP that expanding the criteria to include more pediatric indicators would be useful.For the increasing numbers of people living with conditions that require
                                                         special treatment, such as factor replacement for hemophiliacs, contingency planning and alternative plans are essential elements of care plans.


Non-Member   Jan DeRoche, American        Practice 3     Add - RN and Social Work (SW) case managers meeting individual state licensure requirements and holding appropriate certification in clinical case management to                 No action taken. A particular professional is not singled out,
             Case Management                             work with patients, families and caregivers to develop patient-centered plans of care.                                                                                           reference is made to the entire healthcare team
             Association



Non-Member   Lauren Agoratus, Family      Practice 3      We agree that this is best practices. We are doing a pilot medical home project in NJ with the AAP/PCORE (American Academy of Pediatrics/Pediatric Council on                   Comment incorporated into report. Pilot study referenced
             Voices                                      Research and Education) utilizing these principles with funding from the US Department of Health and Human Services HRSA for an Integrated Community-Based                       within Implementation Approaches
                                                         Systems of Support for Children and Youth with Special Healthcare Needs and their Families.



Non-Member   Lauren Agoratus, Family      Practice 3     Preferred Practice #3 The healthcare home shall develop infrastructure for managing plans of care that incorporate systems for registering, tracking, measuring,                 Comment will be incorporated into report
             Voices                                      reporting, and improving essential coordinated services. We support the additional specifications of including information on the record such as diagnosis, medications,
                                                         allergies, and progress notes.


Non-Member   Lauren Agoratus, Family      Practice 3     Preferred Practice #3 The healthcare home shall develop infrastructure for managing plans of care that incorporate systems for registering, tracking, measuring,                 No action taken given NQF has underway a project to
             Voices                                      reporting, and improving essential coordinated services. We would recommend the use of a federal or state standardized template such as the Universal Health Record              standardize the plan of care data elements within the context
                                                         or Special Care Plan mentioned under preferred practice #6 below.                                                                                                                electronic health records


Member       Lee Anne Gardner,            Practice 3     Plans of care availability. We are unclear about the level of detail that's required for this practice. Updating this to each provider and then assuring reconciliation can be   No action taken. The Committee clearly felt there is one plan
             American College of                         very daunting even for highly integrated systems to accomplish this. Trying to do this could have ramifications in timely access to services.                                    of care and that it be accessible--not that variations of the plan
             Physicians, Performance                                                                                                                                                                                                      be updated periodically and be available to various parties.
             Measurement
             Subcommittee

Member       Mary Naylor, University of   Practice 3     • As written, this practice fails to acknowledge the use of electronic systems for documenting and generating plans of care. Line 331 requires the ―plan of care….written        Comment incorporated into draft report
             Pennsylvania School of                      by the healthcare home…‖ As an alternative, it should read: ―plan of care…documented by the healthcare home…‖
             Nursing



Member       Mary Naylor, University of   Practice 3     Line 344 – The plan of care should not be limited to merely clinical data but should also include functional, social, caregiver burden, etc.                                     Comment incorporated into draft report
             Pennsylvania School of
             Nursing


Member       Mary Naylor, University of   Practice 3     Additionally, this practice should specify that the plan of care reflect patient preferences and caregiver needs. In the practice’s example, the database should be broader Comment incorporated into draft report
             Pennsylvania School of                      than merely medical providers and include all clinical and non-clinical service providers
             Nursing



Member       Michelle Beauchesne,         Practice 3     #3: NAPNAP along with the AAP agree that this proposed preferred practice could be improved considerably. First, we suggest an expansion of the criteria for care                The suggestion of including immunization status to the
             National Association of                     plans to include more specific pediatric indicators beyond the practices reference to growth charts. Other criteria to consider include immunization status, home health         specifications of the report was added. In addition, the
             Pediatric Nurse                             services, educational systems, and early intervention.                                                                                                                           specifications of practice 3 clearly indicate the plan of care
             Practitioners (NAPNAP)                                                                                                                                                                                                       should include age-appropriate standardized clinical
                                                                                                                                                                                                                                          assessments and information regarding social support

Member       Michelle Beauchesne,         Practice 3     Second, the plan should include contingency planning. This is relevant to anyone, child or adult, whose health is dependent on specific supplemental nutritional and/or          Comment incorporated into report.
             National Association of                     treatment requirements. For example, what should be done when supplies are interrupted such as factor replacement for hemophiliacs or infants with metabolic
             Pediatric Nurse                             condition?
             Practitioners (NAPNAP)
Member       Michelle Beauchesne,         Practice 3     Third, the practice should include criteria on portability of the care plan in and across systems.                                                                               Comment incorporated into report.
             National Association of
             Pediatric Nurse
             Practitioners (NAPNAP)




                                                                                                                       NQF DRAFT: DO NOT CITE, QUOTE, REPRODUCE, OR CIRCULATE                                                                                                                                  11
Member       Barbara Rudolph, The         General      The Leapfrog Group supports the National Quality Forum's efforts to address the lack of care coordination evident in our current healthcare delivery environment. The      Comment for which no action can be taken. NQF recognizes
             Leapfrog Group                            Leapfrog Group also supports the effort to develop a comprehensive framework for care coordination measurement. However, the devil is in the details, in particular, the the importance of outcome measures and other NQF projects
                                                       use of terminology that is limiting in terms of application of these metrics. We hope that the National Quality Forum would broaden these preferred practices to all       are currently addressing this issue
                                                       licensed healthcare providers who are delivering "primary care" to patients. In addition, we hope that NQF will quickly address the need for linkage of these practices to
                                                       the outcomes of care. We would like NQF to avoid the same journey through process measures that has occurred with hospital and physician measures.


Member       Michelle Beauchesne,         Practice 3   Fourth, a care plan also must reflect who a child is, what their preferences are, what historically works well, what the team can expect in terms of medical equipment, and     No action taken. The practices indicate that the plan of care is
             National Association of                   more.                                                                                                                                                                           jointly developed with the patient and care providers, and
             Pediatric Nurse                                                                                                                                                                                                           should include the preferences of the patient as it relates to
             Practitioners (NAPNAP)                                                                                                                                                                                                    his/her situation

Member       Michelle Beauchesne,         Practice 3   Fifth, the elements of care plan should include problem orientation but also needs to be balanced by the inclusion of assets/strengths.                                         Practice 6 indicates that an orientation of the patient's problem
             National Association of                                                                                                                                                                                                   will be conducted, the suggestion of balancing this by including
             Pediatric Nurse                                                                                                                                                                                                           patients' assets and strengths was added.
             Practitioners (NAPNAP)


Member       Michelle Beauchesne,         Practice 3   Sixth, the practice should include criteria for health plan payment or incentivization of clinicians development and oversight of the care plan.                                No action taken. Recommending payment intiatives and
             National Association of                                                                                                                                                                                                   incentives for clinicians in regards to implementing the
             Pediatric Nurse                                                                                                                                                                                                           practices is beyond the scope of this project.
             Practitioners (NAPNAP)

Member       Michelle Beauchesne,         Practice 3   Finally, it is unclear how clinical information from non-clinical sources are to be inputted into the record (eg,developmental screen results from licensed child care center   Comment refers to an implementation approach of the
             National Association of                   or a Hemoglobin result from WIC clinic.                                                                                                                                         practice, which only serve as examples.
             Pediatric Nurse
             Practitioners (NAPNAP)


Non-member   Ellen Kurtzman, The George Practice 4     • As stated, this practice is too physician oriented. Nurse practitioners often serve as primary care providers. The practice (line 364) should be restated as follows:         Comment incorporated into draft report. Changes were made
             Washington University,                    ―…support effective collaborations between primary care and specialty care practitioners….‖                                                                                     to the practice statement, incorporating the term 'specialist
             Department of Nursing                                                                                                                                                                                                     provider' to represent other providers, such as nurses and case
             Education                                                                                                                                                                                                                 managers, who may be directly involved in patient care.F281


Member       Ellen Schwalentocker,        Practice 4   The word physicians in line 364 should be replaced with providers. The specifications in this Practice focus predominantly on the collaboration between primary care and Comment incorporated into draft report. Changes were made
             NACHRI                                    specialty providers in a consultant role. Similar, common and important collaboration between primary care providers and emergency medical providers and hospital-       to the practice statement, incorporating the term 'specialist
                                                       based patient care teams should also be specified. Effective collaboration between the healthcare home and the hospital is important in improving safety, increasing     provider' to represent other providers, such as nurses and case
                                                       quality and reducing unnecessary utilization of hospital services.                                                                                                       managers, who may be directly involved in patient care.


Member       Katherine Kany, AFT          Practice 4   "The healthcare home should have policies, procedures and accountabilities to support effective collaborations between primary care and specialty physicians, including Comment incorporated into draft report. Changes were made
             Healthcare                                evidence-based referrals and consultations that clearly define the roles and responsibilities of the patients, caregivers, and primary care and specialist providers."  to the practice statement, incorporating the term 'specialist
                                                       Language should be changed to say "primary care and specialty providers" in keeping with the focus on integrated services and interdisciplinary providers.              provider' to represent other providers, such as nurses and case
                                                                                                                                                                                                                               managers, who may be directly involved in patient care.


Non-Member   Kay Jewell, Centers for      Practice 4   One of the areas of care coordination that also requires attention is the sharing of the plan of care and critical issues with the hospital team. Patients consider             Additional specifiy added to practice to emphasize
             Consumers of Healthcare                   communication between the primary team and hospital team as important - especially about decision-making, issues discussed (short and long-term treatment plans),               communication across multiple care settings
                                                       special circumstances that influence the patient's care. The data suggests that the primary care team has contact with the ED or admitting team in less than 25% of
                                                       admissions.

Non-Member   Lauren Agoratus, Family      Practice 4   Preferred Practice #4 The healthcare home should have policies, procedures and accountabilities to support effective collaborations between primary care and specialty Comment supported current draft, no action necessary
             Voices                                    physicians, including evidence-based referrals and consultations that clearly define the roles and responsibilities of the patients, caregivers, and primary care and
                                                       specialist providers. We strongly support collaboration between primary care physicians (PCPs) and specialists, particularly as it relates to children with special health
                                                       care needs. We agree that utilizing evidence based practices will result on better health outcomes. We concur that payers need to develop incentives for the
                                                       development of care plans. To make this happen, primary care and specialist preparation programs must incorporate the principles of medical home and collaboration
                                                       between primary and specialty care.

Member       Lee Anne Gardner,            Practice 4   We are not clear what an evidence-based referral is or how to judge the appropriateness of such a referral - i.e., if one of our members does not feel they are the best        No action taken. The second specification addreses the
             American College of                       person to evaluate a problem, they will use a referral. Please clarify.                                                                                                         matter.
             Physicians, Performance
             Measurement
             Subcommittee

Member       Mary Naylor, University of   Practice 4    As stated, this practice is too physician oriented. Nurse practitioners often serve as primary care providers. The practice (line 364) should be restated as follows:          Comment incorporated into draft report. Changes were made
             Pennsylvania School of                    ―…support effective collaborations between primary care and specialty care practitioners….‖                                                                                     to the practice statement, incorporating the term 'specialist
             Nursing                                                                                                                                                                                                                   provider' to represent other providers, such as nurses and case
                                                                                                                                                                                                                                       managers, who may be directly involved in patient care.


Member       Michelle Beauchesne,         Practice 4   #4: Collaboration between primary and specialty care Family-centered care should be addressed in this practice. As currently written, the practice does not include family Comment incorporated into draft report. Changes were made
             National Association of                   and youth as part of the process of collaboration and co-management, which should be specifically mentioned in line 364.                                                   to the practice statement, incorporating the term 'specialist
             Pediatric Nurse                                                                                                                                                                                                      provider' to represent other providers, such as nurses and case
             Practitioners (NAPNAP)                                                                                                                                                                                               managers, who may be directly involved in patient care.


Member       Michelle Beauchesne,         Practice 4   A potential measure opportunity could address whether primary and specialty care clinicians have a written co-management agreement that explicitly outlines roles and           Comment incorporated into report.
             National Association of                   responsibilities, such as requiring call-back after consultation and provision of essential information in the referral form. Other opportunities for measurement for this
             Pediatric Nurse                           practice include the use of care plans and electronic record transfer, when available. Sample Implementation Effort: The Alameda County Medical Home Project of
             Practitioners (NAPNAP)                    Alameda County, California has partnered with the regional center for persons with developmental disabilities to design a standardized referral cover sheet for providers
                                                       that clarifies the referral process and provides pediatricians with the information they need for a successful referral. Project staff meet quarterly with regional center
                                                       intake staff to discuss referral-related problems and provide follow-up with providers who the regional center believes are not submitting appropriate referrals.


Member       Pat Ford-Roegner,            Practice 4   If one fundamental aim of this care coordination project truly is to call for provider accountability, the language in Practice Statement #4 must be broadened. As currently Comment incorporated into draft report. Changes were made
             American Academy of                       stated, accountability policies and practices are limited to supporting ―effective collaborations between primary care and specialty physicians.‖ Nurse practitioners        to the practice statement, incorporating the term 'specialist
             Nursing                                   already provide primary care and coordinate care around the country and across settings; the American Academy of Nursing believes that patients and their families           provider' to represent other providers, such as nurses and case
                                                       want all practitioners accountable for providing safe, effective, coordinated care as well, and encourages NQF to endorse such a practice.                                   managers, who may be directly involved in patient care.


Member       Rita Munley Gallagher,       Practice 4   While the American Nurses Association appreciates the use of the verbiage ―healthcare‖ rather than ―medical‖ home and the attendant recognition of a more               Comment incorporated into draft report. Changes were made
             American Nurses                           comprehensive care delivery and team model, the sole focus on research and models emanating from medicine is extremely limited in scope and recommends                  to the practice statement, incorporating the term 'specialist
             Association                               incorporation of healthcare and primary care home models from nursing and other professions. In addition, the American Nurses Association has concerns regarding the provider' to represent other providers, such as nurses and case
                                                       seeming primacy of physicians throughout the document as noted in the following: Page 18: Preferred Practice 4: The healthcare home should have policies, procedures managers, who may be directly involved in patient care.
                                                       and accountabilities to support effective collaborations between primary care and specialty physicians [sic], including evidence based referrals and consultations that
                                                       clearly define the roles and responsibilities of the patients, caregivers, and primary care and specialist providers.

Member       Sheree Chin Ledwell, Aetna Practice 4     Practice Statement #4 speaks to "collaboration between primary care and specialty physicians," but does not address collaboration with community resources and                  Comment incorporated into draft report. Changes were made
                                                       agencies, legal entities (e.g. juvenile probation), child and family services e.g. for foster care, government waiver programs. In addition, primary care practice extends to   to the practice statement, incorporating the term 'specialist
                                                       nurse practitioners and physician assistants.                                                                                                                                   provider' to represent other providers, such as nurses and case
                                                                                                                                                                                                                                       managers, who may be directly involved in patient care.
                                                                                                                                                                                                                                       Practice 9 specify addresses collaboration with community and
                                                                                                                                                                                                                                       nonclinical services.

Non-member   Ellen Kurtzman, The George Practice 5     As stated on line 416, assessment is limited to medical care needs. Instead, this should be stated as ―health needs‖                                                            No action taken
             Washington University,
             Department of Nursing
             Education
Member       Ellen Schwalentocker,        Practice 5   The language describing this Practice should emphasize correct and appropriate utilization instead of overutilization. For instance, at high risk for . . . high service use    No action taken. The Committee felt it was important to have a
             NACHRI                                    should be worded as at high risk for . . . inappropriate service use. Just because a patient is a high user of a particular service at a particular time does not mean that the practice with focus on patients who are at a higher-risk for care
                                                       level of service is inappropriate. In fact, intensive, appropriate care for a brief period may lead to better management and lower, long-term utilization.                      coordination services

Member       Ellen Schwalentocker,        Practice 5   The bullets following the plan of care on line 422 should include be culturally competent and written at appropriate language levels. The opportunities for measurement         Comment incorporated into report
             NACHRI                                    listed at the end of this section are an illustration of the general adult orientation of the report. It is unclear why process measures (such as use of ACE inhibitors and
                                                       angiotensin receptor blocker use are listed as opportunities for measurement.

Non-Member   Jan DeRoche, American        Practice 5   We recommend modifying language as follows – ―The healthcare home will provide or arrange for care coordination services ―delivered by RN or SW with case                       No action taken. A particular professional is not singled out,
             Case Management                           management training and/or certification for patients…‖                                                                                                                         reference is made to the entire healthcare team
             Association

Non-Member   Lauren Agoratus, Family      Practice 5   Preferred Practice #5 The healthcare home will provide or arrange to provide care coordination services for patients at high risk for adverse health outcomes, high             Comment supported current draft, no action necessary
             Voices                                    service use, and high costs. We agree with using the medical home for care coordination which is cost effective but most importantly decreases morbidity and mortality
                                                       rates. This is particularly true of children who have chronic conditions. We agree with the additional specifications that the care plan must be ―individualized and
                                                       incorporate patient and caregiver preferences and goals‖. Even within the same diagnosis, there can be a wide range of how it affects the person depending upon their
                                                       symptoms. In addition, family and professional goals may differ. Lastly, patient preferences will also allow for more cultural competence for providers.


Member       Mary Naylor, University of   Practice 5   As stated on line 416, assessment is limited to medical care needs. Instead, this should be stated as ―health needs‖                                                            No action taken
             Pennsylvania School of
             Nursing

Member       Michelle Beauchesne,         Practice 5   NAPNAP along with the AAP suggests that this practice address children and youth who also are at risk for adverse outcomes in education (eg, school absences),                  Comment incorporated into draft report.
             National Association of                   mental health, and adverse outcomes on family functioning (eg, divorce, missed work days). At times, the focus should not be on reducing high service use, but rather
             Pediatric Nurse                           about increasing more appropriate use of services. Optimizing patient- and family-centered care will have a favorable impact on health care costs, service use, and
             Practitioners (NAPNAP)                    outcomes.

Member       Michelle Beauchesne,         Practice 5   The opportunities for measurement should be expanded beyond the present focus on adult cardiac issues. Specific language revisions follow. Line 418: Change text to             Comment incorporated into report.
             National Association of                   electronic or paper summary to include the option of creating a care plan that is paper-based for practices who lack or are developing electronic health record systems.
             Pediatric Nurse                           Lines 422-25: Add language that reflects a need for culturally competent care plans that are in simple language format. Line 431: Add a stronger word than address for
             Practitioners (NAPNAP)                    the section describing community resources. Suggested revision: Proactively recommend and utilize community resources needed to meet patient/family and caregiver
                                                       needs and goals Lines 440-42: Under the fifth bullet, add language in the second sub-bullet to read development of an individualized plan of care, and functional, social,
                                                       and cultural needs and goals.

Non-Member   Samuel Albrect,              Practice 5    The services and required skills speak directly to the scope of practice of case management and the qualifications of certified case managers, as defined by the               No action taken. Committee did not appear to want to limit this
             Commission for Case                       CCMC, which is: ―a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet the client’s           practice to certified case managers only. These practice are
             Manager Certification                     health and human services needs.‖ (http://www.ccmcertification.org/pages/13frame_set.html).                                                                                     intended to be broadly applicable and include all care provider
                                                       Case management, as an advanced practice within the health and human services professions, facilitates ―the achievement of client wellness and autonomy through                 groups
                                                       advocacy, assessment, planning, communication, education, resource management, and service facilitation.‖ As the CCMC states, based on the needs and values of
                                                       the clients, and in collaboration with service providers, the case manager ―links clients with appropriate providers and resources throughout the continuum of health and
                                                       human services and care settings, while ensuring that the care provided is safe, effective, client-centered, timely, efficient, and equitable.‖
                                                       (http://www.ccmcertification.org/pages/13frame_set.html)
                                                       The CCMC strongly believes that certification is the preferred way to demonstrate that a case manager possesses education, knowledge, and experience required to
                                                       render appropriate services delivered according to sound principles, including evidence-based practice. We strongly recommend that the NQF include certification of
                                                       case managers as part of Preferred Practice 5.

Member       Sheree Chin Ledwell, Aetna Practice 5     Practice Statement #5 specifies "The healthcare home shall provide or arrange to provide care coordination services…" but this does not address external agencies and No action taken. The report emphasizes providing care
                                                       community services                                                                                                                                                    coordination services broadly and does not exclude external
                                                                                                                                                                                                                             agencies or community services.

Member       Sheree Chin Ledwell, Aetna Practice 5     The targeted assessment should, in addition to identifying risk factors, identify opportunities to increase protective factors, whether functional, cognitive, medical,         Report was modfied to include preventive health.
                                                       behavioral, or social




                                                                                                                     NQF DRAFT: DO NOT CITE, QUOTE, REPRODUCE, OR CIRCULATE                                                                                                                                12
Member       Barbara Rudolph, The         General      The Leapfrog Group supports the National Quality Forum's efforts to address the lack of care coordination evident in our current healthcare delivery environment. The      Comment for which no action can be taken. NQF recognizes
             Leapfrog Group                            Leapfrog Group also supports the effort to develop a comprehensive framework for care coordination measurement. However, the devil is in the details, in particular, the the importance of outcome measures and other NQF projects
                                                       use of terminology that is limiting in terms of application of these metrics. We hope that the National Quality Forum would broaden these preferred practices to all       are currently addressing this issue
                                                       licensed healthcare providers who are delivering "primary care" to patients. In addition, we hope that NQF will quickly address the need for linkage of these practices to
                                                       the outcomes of care. We would like NQF to avoid the same journey through process measures that has occurred with hospital and physician measures.


Member       Barbara Rudolph, The         Practice 6   The Leapfrog Group would like to see Practice 6 "create, document, execute, and update a plan of care with every patient" extended to apply to all physicians/other              Practice statement indicates this practice should be
             Leapfrog Group                            licensed caregivers. In fact, this would be considered "as meeting conditions of participation" for most payers. Thus, taking this one step further would be to measure the      implemented by healthcare providers, which include all
                                                       percent of provider's patients with current plans of care. And, to measure whether the patient is aware of the care plan through a care experience survey and whether the        physicians/other licensed caregivers. The opportunities for
                                                       provider has shared the care plan with patient permission with the rest of the caregivers. This should not be limited by existing specialty specific measures.                   measurement is not intended to be limiting, but rather identifies
                                                                                                                                                                                                                                        those plan of care measures currently endorsed by NQF.




Non-Member   Charles Willmarth, American Practice 6    Preferred Practice 6: The healthcare home should have structured and effective systems, policies, procedures, and practices to create, document, execute, and update Comment incorporated into report
             Occupational Therapy                      a plan of care with every patient. AOTA requests that NQF add the following bullet (additions in italics) under the section ―Elements of the plan of care should include, but
             Association                               are not limited to‖: evaluating participation and enabling engagement in meaningful occupations (e.g., activities of daily living (ADLs))



Member       Christine Chen, Pacific      Practice 6   Please clarify why the creation of a plan of care is limited to the healthcare home domain. Having a comprehensive plan of care is something that should be done by all Comment incorporated into report
             Business Group on Health                  providers, regardless of the type of delivery model in which a patient is receiving care. The plan should include, among all the clinical aspects of a patients’ condition, the
                                                       party or entity whom is to be held accountable for coordinating

Member       Debra Ness, National      Practice 6      Having a comprehensive plan of care is something that should be done by all providers, regardless of the type of delivery model in which a patient is receiving care.            Comment incorporated into report
             Partnership for Women and                 Please clarify – and revise – so that it is clear that the creation of a plan of care is NOT limited to the healthcare home domain.
             Families

Member       Debra Ness, National      Practice 6      Besides broadening its application, the practice should be revised to make sure that the plan includes, in addition to the clinical aspects of a patients’ condition, the        The practice denotes an accountable provider, but does not
             Partnership for Women and                 party or entity whom is to be held accountable for coordinating the patient’s care.                                                                                              specify an individual and/or particular expertise/profession so
             Families                                                                                                                                                                                                                   as to provide flexibility in implementation.


Non-member   Ellen Kurtzman, The George Practice 6     • It is not clear why the practice of creating a plan of care should be limited to healthcare homes. Creating a plan of care should be an expectation of all providers and       Comment incorporated into draft report.
             Washington University,                    especially those that serve in care coordination roles.
             Department of Nursing
             Education

Non-member   Ellen Kurtzman, The George Practice 6     As stated the list of elements of the plan of care does not include the accountable party/entity responsible for action steps. This should be added.                             No action taken. Specification under practice addresses
             Washington University,                                                                                                                                                                                                     accountability
             Department of Nursing
             Education

Non-member   Ellen Kurtzman, The George Practice 6      In the ―opportunity for measurement‖ a number of measures are listed that appear unrelated to the practice. Vascular access, oncology/chemo measures, etc. are too              No action taken. At this point in time, the measures listed are
             Washington University,                    narrow. Throughout the report, this section should provide a crosswalk to measures that hold providers accountable for the delivery of the practice not merely a list of         cast generally to address the plan of care. Certain specialties
             Department of Nursing                     measures that are related ever so remotely.                                                                                                                                      require different plans of care.
             Education

Member       Ellen Schwalentocker,        Practice 6   The recognition of joint creation of the plan by the patient, caregiver and care provider under additional specifications is good. The specifications in this section            No action taken. The communication checklist will be
             NACHRI                                    emphasize ongoing management of chronic disease. The practice may be more effectively specified by acknowledging the importance of coordinating care across the                  incorporated as an implementation example
                                                       continuum, including preventive care. Elements of the plan of care should also include recommendations for prevention and anticipatory guidance. The opportunity for
                                                       measurement for this practice is, again, adult-centric and the link between these measures and care coordination is not always obvious. We are intrigued by the
                                                       communication checklist mentioned by the AAP as a potential implementation approach.


Member       Gayle Fortner, HC21          Practice 6   Please clarify why the creation of a plan of care is limited to the healthcare home domain. Having a comprehensive plan of care is something that should be done by all Comment incorporated.
                                                       providers, regardless of the type of delivery model in which a patient is receiving care. The plan should include, among all the clinical aspects of a patients’ condition, the
                                                       party or entity whom is to be held accountable for coordinating the patient’s care


Member       Katherine Kany, AFT          Practice 6   The plan of care should be a living document that moves with the patient, is a single source of information for everyone, and is continually updated to reflect most current No action taken.
             Healthcare                                information, goals, medications and treatments. This model fits with both #16 and #17 and increases the likelihood that information is always up to date.



Non-Member   Lauren Agoratus, Family      Practice 6   Preferred Practice #6 The healthcare home should have structured and effective systems, policies, procedures, and practices to create, document, execute, and update Comment supports draft, template will be referenced as an
             Voices                                    a plan of care with every patient. We strongly support the use of a care plan. In NJ, we also have universal child health records http://www.state.nj.us/health/forms/ch-    implementation example
                                                       14.pdf and care plans for children with special health care needs http://www.state.nj.us/health/forms/ch-15.pdf which could serve as a template. We agree with the
                                                       additional specifications that ―environmental or social factors may contribute to the problem.‖ For example, during our parent focus groups, in some cultures women were
                                                       afraid to tell their husbands not to smoke around the children. By addressing social factors, providers will incorporate more culturally competent care, resulting in better
                                                       health outcomes. We also strongly support assessment of the patient’s health literacy status, which will improve care and outcomes.


Member       Mary Naylor, University of   Practice 6    • It is not clear why the practice of creating a plan of care should be limited to healthcare homes. Creating a plan of care should be an expectation of all providers and      Comment incorporated in draft report
             Pennsylvania School of                    especially those that serve in care coordination roles.
             Nursing

Member       Mary Naylor, University of   Practice 6   As stated the list of elements of the plan of care does not include the accountable party/entity responsible for action steps. This should be added.                             No action taken. Specification under practice addresses
             Pennsylvania School of                                                                                                                                                                                                     accountability
             Nursing
Member       Mary Naylor, University of   Practice 6   In the ―opportunity for measurement‖ a number of measures are listed that appear unrelated to the practice. Vascular access, oncology/chemo measures, etc. are too               No action taken. At this point in time, the measureS listed are
             Pennsylvania School of                    narrow. Throughout the report, this section should provide a crosswalk to measures that hold providers accountable for the delivery of the practice not merely a list of         cast generally to address the plan of care. Certain specialties
             Nursing                                   measures that are related ever so remotely.                                                                                                                                      require different plans of care.



Member       Michelle Beauchesne,         Practice 6   #6. Healthcare home plan to create, execute and update care plan: NAPNAP along with the AAP urges the NQF to incorporate into this practice language that is          Commentor suggestions on including preventive care within the
             National Association of                   consistent with care coordination within a medical home for primary care practice, which includes emphasis on preventive, acute, and chronic care. The AAP and the    specifications of the practice was incorporated, and the
             Pediatric Nurse                           National Center for Medical Home Implementation (NCMHI) encourage practices to utilize a communication checklist to assess how they promote patient access and        checklist is added as an implementation example
             Practitioners (NAPNAP)                    quality communication. This checklist (available at www.pediatricmedhome.org) encourages practices to document quantitatively the following results: visits with
                                                       assigned personal clinician for each patient (eg, the percentage of patients seen in last month who saw their personal clinician);
                                                       appointments scheduled to meet the standards in the communication checklist (eg, coordinated visits or percentage of patients seen in last month on same day called);
                                                       response times to meet standards for telephone, email requests (per above) (eg, time tracking for last weeks emails and average response time); and language services
                                                       offered for patients with limited English proficiency.

Non-member   Ellen Kurtzman, The George Practice 7     • At online 592, this practice should specify the accountable party to whom these reminders be sent.                                                                             No action taken. Text clarifies the reminders go to the patient.
             Washington University,
             Department of Nursing
             Education

Non-Member   Lauren Agoratus, Family      Practice 7   Preferred Practice #7 A systematic process of follow-up tests, treatments, or services should be established and be informed by the plan of care. We agree that follow-          Comment supported current draft, no action necessary
             Voices                                    up is essential for better health outcomes. We also agree that good opportunities for measurement are ―patient satisfaction with care.‖


Member       Mary Naylor, University of   Practice 7   • At online 592, this practice should specify the accountable party to whom these reminders be sent.                                                                             No action taken. Text clarifies the reminders go to the patient.
             Pennsylvania School of
             Nursing

Member       Michelle Beauchesne,         Practice 7   #7: Care plan systematic process of follow-up tests, treatments, and services: This practice should include reference to care plans that must be shared across            No action taken. Commentor suggestions are already
             National Association of                   organizations with permission of family. The locus of accountability (line 590) is an intriguing, positive addition for the medical home, but it also must reflect family addressed within the specifications of the practice, which
             Pediatric Nurse                           preferences. Although coordination of tests, treatment, and services is noted in the additional specifications of this practice, coordination should be inserted into the indicate how the plan of care should be shared and what types
             Practitioners (NAPNAP)                    main practice to add greater clarity. We offer the following rewording to lines 58-81: be established and be informed and coordinated by the plan of care. Additional     of information should be communicated to the healthcare team
                                                       revisions include: Line 597: add at risk for after patients. Line 615: add types of patient information that should be communicated to the healthcare home team members.


Non-Member   Samuel Albrect,              Practice 7   Preferred Practice 7 (lines 595-602) states that ―systems should be in place to proactively remind the patient and clinician of services needed,‖ such as those related to  No action taken. Committee did not appear to want to limit this
             Commission for Case                       pre-visit planning, clinician review or action, a particular medication, preventive care, specific tests, and care management services. The language lacks specific mention practice to certified case managers only. These practice are
             Manager Certification                     of a case manager/care coordinator to coordinate or manage these activities and to own this process. We strongly suggest that this would be an important opportunity        intended to be broadly applicable and include all care provider
                                                       to highlight the valued-based role and contribution of the case manager in the care coordination process and recommend that the NQF consider a modification to correct groups
                                                       this omission in Preferred Practice 7.

Member       Sheree Chin Ledwell, Aetna Practice 7     Practice Statement #7 specifies "A systematic process of follow-up tests, treatments, or services." This should also include behavioral health assessments for both              Report was modified to include behavioral-health related
                                                       children and adults.



Member       Carol Sakala, Childbirth     Practice 8   Please clarify why the creation of a care plan is limited to the health care home. All caregivers should have a comprehensive care plan, regardless of setting and delivery Comment incorporated into report. It is not intended for the
             Connection                                model. In every case, this should identify the party or entity accountable for overall coordination.                                                                        plan of care to be limited to the healthcare home, further
                                                                                                                                                                                                                                   clarification was added to the report reflecting this.


Member       Christine Chen, Pacific      Practice 8   Please clarify and revise this practice to specify that the joint plan of care must include information that will assist the patient and/or family caregivers in obtaining       Specifications of the practice clearly make reference to the
             Business Group on Health                  educational support, as well as support and resources for self-management. Providing support and education for the family caregiver is extremely important, particularly         patient and their designees. No further action taken
                                                       in cases where the patient has cognitive impairment.

Member       Debra Ness, National      Practice 8      This practice should be revised to specify that the joint plan of care must include information that will assist the patient and/or family caregivers in obtaining educational   Specifications of the practice clearly make reference to the
             Partnership for Women and                 support, as well as support and resources for self- management. Providing support and education for the family caregiver is extremely important, particularly in cases           patient and their designees. No further action taken
             Families                                  where the patient has cognitive impairment.

Member       Ellen Schwalentocker,        Practice 8   The language in this Practice is written for the adult patient perspective and several times refers to the patient (or designee). This is not necessarily inclusive of the       Comment incorporated into report.
             NACHRI                                    relationship of parents/legal guardians and children. Wording throughout the section should be adjusted to recognize the role of parents / legal guardians in receiving
                                                       education and support for self-management and resources.

Member       Gayle Fortner, HC21          Practice 8   Please clarify and revise this practice to specify that the joint plan of care must include information that will assist the patient and/or family caregivers in obtaining       Specifications of the practice clearly make reference to the
                                                       educational support, as well as support and resources for self-management. Providing support and education for the family caregiver is extremely important, particularly         patient and their designees. No further action taken
                                                       in cases where the patient has cognitive impairment.
Non-Member   Lauren Agoratus, Family      Practice 8                                                                                                                                                                                    Comment supported current draft, implementation examples
             Voices                                                                                                                                                                                                                     will be referenced in report
                                                       Preferred Practice #8 The joint plan of care should be developed and include patient education and support for self-management and resources. We concur that patient
                                                       education is helpful in care management. Patients who share in decision-making and self management have better health outcomes. An example of this is Health Dialog
                                                       at http://www.healthdialog.com/Main/PersonalHealthCoaching/SharedDecisionMaking . In NJ we use the Take Control of Your Health program found at
                                                       www.state.nj.us/health/senior/healthease.shtml#control. We agree under additional specifications that patient education must include not only the patient but their
                                                       designee, such as a family caregiver, where appropriate. We also agree that the care plan should ―account for financial expenses‖ and include referrals to appropriate
                                                       supports such as the Catastrophic Illness Relief Fund in NJ under Title V. A recent report (source CNN) indicated that 60% of bankruptcies are due to medical expenses.

Member       Michelle Beauchesne,         Practice 8   #8: Joint care plan include patient education and support for self-management and resources. NAPNAP along with the AAP urges the NQF to recognize the healthcare             Comment incorporated into report.
             National Association of                   related needs of children conceptually by revising the practice to read: "The joint plan of care should be developed and include patient, the patients education (or parents
             Pediatric Nurse                           education, if an infant or child), and the patients medical surrogate (for incompetent adult patients).
             Practitioners (NAPNAP)

Member       Sheree Chin Ledwell, Aetna Practice 8     Practice Statement #8 includes ―support for self-management,‖ however this needs clarification as to intent. A prevention plan is unique to the member's symptoms and No action taken. Comment is unclear as to why and how
                                                       circumstances to help identify those behaviors and symptoms that the patient recognizes triggers the beginning of issues that potentially end in acute care episodes, e.g. "intent" needs to be clarified.
                                                       noncompliance with medications or diet. They then identify those steps to take to remedy the situation early, e.g. call for medical home support.


Member       Sheree Chin Ledwell, Aetna Practice 8     We agree under additional specifications that patient education must include not only the patient but their designee, such as a family caregiver, where appropriate.             Comment supports draft report




                                                                                                                     NQF DRAFT: DO NOT CITE, QUOTE, REPRODUCE, OR CIRCULATE                                                                                                                                 13
Member       Barbara Rudolph, The         General       The Leapfrog Group supports the National Quality Forum's efforts to address the lack of care coordination evident in our current healthcare delivery environment. The      Comment for which no action can be taken. NQF recognizes
             Leapfrog Group                             Leapfrog Group also supports the effort to develop a comprehensive framework for care coordination measurement. However, the devil is in the details, in particular, the the importance of outcome measures and other NQF projects
                                                        use of terminology that is limiting in terms of application of these metrics. We hope that the National Quality Forum would broaden these preferred practices to all       are currently addressing this issue
                                                        licensed healthcare providers who are delivering "primary care" to patients. In addition, we hope that NQF will quickly address the need for linkage of these practices to
                                                        the outcomes of care. We would like NQF to avoid the same journey through process measures that has occurred with hospital and physician measures.


Non-Member   Charles Willmarth, American Practice 9     AOTA respectfully requests that the role of occupational therapy be recognized in Preferred Practices 6, 9 and 10 with regard to lifestyle therapy, education and                Comment incorporated into draft report
             Occupational Therapy                       counseling activities and participation in life and community activities:
             Association
                                                        Preferred Practice 9: The plan of care should include community and nonclinical services as well as healthcare services that respond to a patient’s needs and
                                                        preferences and contributes to achieving the patient’s goals.

Non-member   Ellen Kurtzman, The George Practice 9       • As one example of inconsistency, this practice (line 673) categorizes services as ―community and nonclinical‖ whereas previously they were referred to as ―medical            The two lines in the comment (673 & 354) were not intended to
             Washington University,                     and non medical‖ (line 354). Consistency within and across these practices must be achieved.                                                                                     be standardized, they are addressing two different things. Line
             Department of Nursing                                                                                                                                                                                                       673 was not changed, the reference to community and
             Education                                                                                                                                                                                                                   nonclinical was intentional. Suggestion for line 354 was
                                                                                                                                                                                                                                         incorporated into report

Non-member   Ellen Kurtzman, The George Practice 9       It is not clear why the plan of care should recognize ―regional health and public health resources‖ (line 680) to the exclusion of local and/or national resources. These       Comment incoporated into draft report
             Washington University,                     resource levels should be incorporated into the practice.
             Department of Nursing
             Education

Member       Ellen Schwalentocker,        Practice 9    With the advent of personal information technologies such as social networking and personal technology applications, patient support networks and resources may be                Comment incoporated into draft report
             NACHRI                                     national in nature. This is particularly true for children with serious conditions and their families. The specification bullet beginning on line 680 should expand the source of
                                                        resources beyond community and region to national.
Non-Member   Lauren Agoratus, Family      Practice 9     Preferred Practice #9 The plan of care should include community and nonclinical services as well as healthcare services that respond to a patient’s needs and                    Comment supported current draft report, no action necessary
             Voices                                     preferences and contributes to achieving the patient’s goals. We agree that community supports can enhance medical care, are cost effective, and result in better
                                                        outcomes. We support the additional specifications of a patient needs assessment to determine ―factors which may affect care such as transportation.‖ This may be
                                                        another opportunity to utilize telehealth. We also concur with referrals to ―community advocates‖ such as the Family-to-Family Health Information Centers and Family
                                                        Voices and Federation of Families for Children’s Mental Health parent/family organizations.



Member       Mary Naylor, University of   Practice 9    • As one example of inconsistency, this practice (line 673) categorizes services as ―community and nonclinical‖ whereas previously they were referred to as ―medical and The two lines in the comment (673 & 354) were not intended to
             Pennsylvania School of                     non medical‖ (line 354). Consistency within and across these practices must be achieved.                                                                                  be standardized, they are addressing two different things. Line
             Nursing                                                                                                                                                                                                              673 was not changed, the reference to community and
                                                                                                                                                                                                                                  nonclinical was intentional. Suggestion for line 354 was
                                                                                                                                                                                                                                  incorporated into report
Member       Mary Naylor, University of   Practice 9    It is not clear why the plan of care should recognize ―regional health and public health resources‖ (line 680) to the exclusion of local and/or national resources. These comment incorporated into draft report
             Pennsylvania School of                     resource levels should be incorporated into the practice.
             Nursing
             Michelle Beauchesne,         Practice 9    #9: Community and nonclinical services. Access issues as well as legal and advocacy services should be incorporated into the additional specifications related to this           No action taken. The practice references nonclinicial services
             National Association of                    practice.                                                                                                                                                                        which can include legal and advocacy services
             Pediatric Nurse
             Practitioners (NAPNAP)
Member       Michelle Beauchesne,         Practice 9    Also, line 687 should note that care plans should begin with the assessment of the child/youth and family needs (i.e., assessment, goal setting, care planning, and              No action taken. The specifications of the practice clearly
             National Association of                    monitoring is cyclical). The AAP and NCMHI toolkit, Building Your Medical Home (www.pediatricmedhome.org), includes a Resources and Linkages Checklist for                       indicate a needs assessment, which include goal setting, care
             Pediatric Nurse                            practices to assess their knowledge of and referral to community services such as family to family supports, state-funded family relief, and condition-specific patient          planning, and monitoring.
             Practitioners (NAPNAP)                     education materials/classes.
Member       Sheree Chin Ledwell, Aetna Practice 9      Practice Statement #9 includes a plan of care that ―respond to a patient’s needs and preferences.‖ The plan of care should also be based on root causes, e.g., social            The third specification clearly states social factors such as
                                                        factors or lack of transportation, and focused on outcomes and evidence-based interventions.                                                                                     housing and transportation must be accounted for.
                                                                                                                                                                                                                                         Specifications for practice 6 were modified to indicated the
                                                                                                                                                                                                                                         plan of care should include desired outcomes and appropriate
                                                                                                                                                                                                                                         evidence-based interventions

Member       Barbara Rudolph, The         Practice 10   This practice should be extended to all patients in need of additional rehabilitation services following surgical procedures.                                                    No action taken. Comment to be passed on to the practice
             Leapfrog Group                                                                                                                                                                                                              developer for further evaluaiton
Member       Carol Sakala, Childbirth     Practice 10   We are concerned about the justification for a practice that is so narrowly defined as to apply to one subset of clinical conditions. All patients should receive competent      No action taken. Evidence base suports practices as written
             Connection                                 attention to care coordination, not just cardiac patients.



Non-Member   Charles Willmarth, American Practice 10    Preferred Practice 10: Healthcare organizations should use cardiac rehabilitation services to coordinate care for patients with a recent cardiovascular event, where             No action. specification currently makes reference to lifestyle
             Occupational Therapy                       available, appropriate, and accessible.                                                                                                                                          therapy, which we believe emcompasses the comment
             Association
                                                        Under Preferred Practice 10, the recommendation is that ―An individualized treatment plan is then designed and implemented that includes a comprehensive program of
                                                        lifestyle therapy, education, counseling, and medical treatments, all of which are done in coordination with the patient’s primary medical care provider.‖

                                                        AOTA requests that additional language be added to the ―Additional Specifications‖ (such as the language recommended in italics here) to recognize the cardiac
Non-Member   Charles Willmarth, American Practice 10    According to CMS in the Proposed Rule, a cardiac rehabilitation program is physician-supervised and would include the following: physician-prescribed exercise; cardiac No action. The practice does not specify who is permitted to
             Occupational Therapy                       risk factor modification, including education, counseling, and behavioral intervention; psychosocial assessment; and outcomes assessment. Occupational therapy          bill for what services
             Association                                practitioners are educated to provide many of these skilled interventions and do provide them currently, billing the services as therapy.

Member       Christine Chen, Pacific      Practice 10   Please clarify the rationale behind having a practice that is so narrowly defined as to apply only to one subset of clinical conditions. All patients should be provided with    No action taken. The Committee felt it was important to
             Business Group on Health                   care coordination supports, not just cardiac patients.                                                                                                                           highilight this high risk population in care coordination.

Member       Debra Ness, National      Practice 10      What is the purpose of having a practice that is so narrowly defined as to apply only to one subset of clinical conditions? All patients should be provided with                 No action taken. The Committee felt it was important to
             Partnership for Women and                  care coordination supports, not just cardiac patients.                                                                                                                           highilight this high risk population in care coordination.
             Families


Non-member   Ellen Kurtzman, The George Practice 10     • As stated, this practice is out of the project’s scope. It fails to meet the definition of care coordination as defined by NQF.                                                The Committee felt it was important to highlight a practice
             Washington University,                     • NQF and its membership should support all patients receiving whatever services they need rather than this more narrow practice which limits what is provided among             related to the high risk popualtion. Citations for the approariate
             Department of Nursing                      cardiac population.                                                                                                                                                              evidence base will be reviewed and added to report, as
             Education                                  • Any N QF NVCS should be evidence-based. What supports the following statement: ―Eligible patients should be referred by the inpatient care team to an outpatient               appropriate
                                                        cardiac rehab program…‖?
                                                        • Furthermore, this practice is not sufficiently generalizable to be supported as a national voluntary consensus standard for care coordination.

Member       Ellen Schwalentocker,        Practice 10   Although cardiac rehabilitation services are an excellent example of the application of care coordination, this practice does not seem to fit in the document and potentially Practice pairs well with measures addressing cardiac
             NACHRI                                     detracts from the cross-cutting nature of the issue and the report. We would suggest omitting this practice or incorporating examples as implementation approaches            rehabilitation. Explanatory text will be added to draft report as
                                                                                                                                                                                                                                      to why it's singled out.

Member       Gayle Fortner, HC21          Practice 10   Please clarify the rationale behind having a practice that is so narrowly defined as to apply only to one subset of clinical conditions. All patients should be provided with    No action taken. The Committee felt it was important to
                                                        care coordination supports, not just cardiac patients.                                                                                                                           highilight this high risk population in care coordination.

Non-Member   Kay Jewell, Centers for      Practice 10    Use of rehabilitation is important for all patients. Use of pulmonary rehabiliation for patients with COPD is noticably missing from this document. COPD results in major       No action taken. Committee felt it was important to highlight
             Consumers of Healthcare                    health care cost. The current gap between the GOLD guidelines and clinical practice places patients at unnecessary risk of repeat exacerbations, loss of pulmonary               this population who is at high risk for care coordination
                                                        function and decline in quality of life.
Member       Laura Blum, The Heart        Practice 10   A proactive plan of care is the building block of care coordination for patients with cardiovascular disease. When implemented, this practice encourages patient’s self-         No action taken. The term "accessible" present within the
             Rhythm Society                             disease management, has the potential to reduce the prevalence and severity of cardiovascular disease and promotes the appropriate management of co-morbidities.                 practice statement is intended to refer to those patients who
                                                        The Heart Rhythm Society suggests that the Steering Committee clarify the term ―accessible‖. In this context, does it mean that coordinated care will only occur if there        may not have cardiac rehabilitation services within a suitable
                                                        is access to healthcare? If so, what type of access (e.g., access to health insurance; geographic access, availability of a program onsite)? The term, ―accessible‖ should       distance.
                                                        be further specified to avoid confusion about the practice’s applicability; particularly, if the intent of ―accessible‖ refers to whether an organization has cardiac
                                                        rehabilitation services.
Non-Member   Lauren Agoratus, Family      Practice 10                                                                                                                                                                                    Practice pairs well with measures addressing cardiac
             Voices                                                                                                                                                                                                                      rehabilitation. Explanatory text will be added to draft report as
                                                         Preferred Practice #10 Healthcare organizations should use cardiac rehabilitation services to coordinate care for patients with a recent cardiovascular event, where            to why it's singled out.
                                                        available, appropriate, and accessible. As this appears to be a general document, we’re unsure as why there is a focus on a particular condition.

Member       Mary Naylor, University of   Practice 10   • As stated, this practice is out of the project’s scope. It fails to meet the definition of care coordination as defined by NQF.                                                The Committee felt it was important to highlight a practice
             Pennsylvania School of                     • NQF and its membership should support all patients receiving whatever services they need rather than this more narrow practice which limits what is provided among             related to the high risk popualtion. Citations for the approariate
             Nursing                                    cardiac population.                                                                                                                                                              evidece base will be reviewed and added to report
                                                        • Any N QF NVCS should be evidence-based. What supports the following statement: ―Eligible patients should be referred by the inpatient care team to an outpatient
                                                        cardiac rehab program…‖?
                                                        • Furthermore, this practice is not sufficiently generalizable to be supported as a national voluntary consensus standard for care coordination.

Non-Member   Charles Willmarth, American Practice 11    AOTA agrees with all these Preferred Practice descriptions and further asserts that occupational therapists plays an important role and fills a void in the daily care and       Comment incorporated as an implementation example for the
             Occupational Therapy                       training of both patient and caregivers to assist the patient in achieving their everyday activities and to participate in life in a meaningful manner. For this reason, AOTA    practice
             Association                                requests an expansion of the concept of communication and care coordination to the unique role of occupational therapy practitioners, as follows:

                                                        Communication among primary care providers, hospital providers, specialists and community resources is key for optimal care of patients. Currently, communication
                                                        has become the forefront of many hospital programs as a vehicle to improve transitions and reduce medical errors and rehospitalizations. Several hospitals have
                                                        successfully implemented patient-centered strategies that address gaps in communications by including a family member, caregiver, therapist [occupational therapist], or
                                                        a nurse care coordinator in the care of a patient in the hospital.

                                                        In fact, an article by Gitlin et al. about Project ACT (Advancing Caregiver Training) highlights the role of occupational therapy and how the therapy is coordinated well with
                                                        the care of an advance practice nurse. AOTA has pasted relevant sections below:
                                                        (***See email for full letter and attachments, referencing this article in detail- also because submission form does not permit me to show italics for AOTA's edits).



Member       Ellen Schwalentocker,        Practice 11   We agree with the recommendation by the AAP and NAPNAP to state explicitly the importance of communication and patient/family role in the introduction of this                   Comment incorporated into draft report
             NACHRI                                     domain, the need to address health literacy, translators, and other communication modalities such as email for provider/patient/family communication, and telehealth
                                                        visits and consultations, the recommendation to seek patient/family input and establish patient and family advisory boards, expert panels, and other decision-influencing
                                                        bodies and the suggestion to address family presence as strategy to improve communication. We would encourage the inclusion of wording regarding the
                                                        parent/guardian and family in this section (e.g., line 779). Practice 11
                                                        As noted above, this practice presents an opportunity to emphasize the importance of the patient/familys role in creating the care plan, not merely as passive recipients
                                                        of it.

Non-Member   Kay Jewell, Centers for      Practice 11   The comprehensive plan of care should also be made available immediately to the ED and hospital team. Communication with this team is very important to more               Additional specification added to practice 11 to address the
             Consumers of Healthcare                    efficient hospital stays, increased patient satisfaction and reduced frustration created by the inability of the healthcare team to communicate especially between the     plan of care availability to other specialities besides the
                                                        primary care setting and the hospital team. Until the gap between patients understanding of their health issues and the providers perspective on the patient's problems is healthcare home team
                                                        reduced, it is important that the healthcare team provide better communication between the ambulatory setting and the hospital team. Information provided by patients is
                                                        often not considered reliable when in fact they are communicating back what they have been told is the logic of the current treatment/plan of care and what they
                                                        understand is their health problem.

Non-Member   Lauren Agoratus, Family      Practice 11   Preferred Practice #11 The patient’s plan of care should always be made available to the healthcare home team, the patient, and their designees. We agree that the plan Comment supported current draft report, no action necessary
             Voices                                     must be accessible, yet compliant with HIPAA (Health Insurance Portability and Accountability Act) and FERPA (Family Educational Rights and Privacy Act) regulations.
                                                        We were pleased to see the inclusion of patient designees, such as family caregivers, where appropriate.

Member       Michelle Beauchesne,         Practice 11   NAPNAP along with the AAP urge the NQF to state explicitly the importance of communication and patient/family role in the introduction of this domain. Communication Comment incorporated into draft report
             National Association of                    is the essential modality of care coordination. The patient and family are at the center of the ideal model for effective communication in health care. Also, while it is
             Pediatric Nurse                            shocking that only 25% of discharge summaries reach primary care physicians, it is important to note that patients and families rarely receive copies of these
             Practitioners (NAPNAP)                     summaries. Best practices for care coordination would include sending families copies of important discharge summaries, referral letters, and other important
                                                        documents. This domain also should address health literacy, translators, and other communication modalities such as email for provider/patient/family communication,
                                                        and telehealth visits and consultations. The domain also should state that practices seek patient/family input and establish patient and family advisory boards, expert
                                                        panels, and other decision-influencing bodies. Finally, we encourage the NQF to address family presence as strategy to improve communication. Family presence in the
                                                        emergency department and unrestricted visiting hours with overnight family accommodations are standard in childrens hospitals and would be similarly welcomed for
                                                        patients across the life span.
Member       Michelle Beauchesne,         Practice 11   Preferred Practice 11: Care plan available to healthcare home team and patients. NAPNAP along with the AAP suggest that this practice include clearly defined                    No action taken. Practice 13 indicates the use of a care
             National Association of                    expectations regarding responsibilities of each member of the care team, including the patient and the family. Also, the areas on self-management and                            partner, who maybe a family member, to assist and
             Pediatric Nurse                            compliance/adherence should reflect family partnership in ongoing care, and skill assessment needs to be accompanied by empowering the family to manage the                      management care of the patient
             Practitioners (NAPNAP)                     condition and/or situation.


Member       Ellen Schwalentocker,        Practic 12    Care coordination is a partnership between the healthcare team, support resources and the patient / caregivers. The additional specification addressing the contributions No action taken
             NACHRI                                     of patients to the care plan is good, but, again, the later bullet on opportunities to ask questions seems to take away from the role of patients in shared decision-making.




                                                                                                                      NQF DRAFT: DO NOT CITE, QUOTE, REPRODUCE, OR CIRCULATE                                                                                                                                  14
Member       Barbara Rudolph, The         General       The Leapfrog Group supports the National Quality Forum's efforts to address the lack of care coordination evident in our current healthcare delivery environment. The      Comment for which no action can be taken. NQF recognizes
             Leapfrog Group                             Leapfrog Group also supports the effort to develop a comprehensive framework for care coordination measurement. However, the devil is in the details, in particular, the the importance of outcome measures and other NQF projects
                                                        use of terminology that is limiting in terms of application of these metrics. We hope that the National Quality Forum would broaden these preferred practices to all       are currently addressing this issue
                                                        licensed healthcare providers who are delivering "primary care" to patients. In addition, we hope that NQF will quickly address the need for linkage of these practices to
                                                        the outcomes of care. We would like NQF to avoid the same journey through process measures that has occurred with hospital and physician measures.


Member       Ellen Schwalentocker,        Practice 12   Opportunities for measurement might include patient or caregiver awareness of mechanisms to review and discuss plan of care as well as documentation of participation Comment incorporated into report
             NACHRI                                     in plan of care discussions.


Non-Member   Lauren Agoratus, Family      Practice 12   Preferred Practice #12 All healthcare home team members, including patients and their designees, should work within the same plan of care and share responsibility for            Comment supported current draft report, no action necessary
             Voices                                     their contributions to the plan of care and achieving the patient’s goals. We support the concept of shared responsibility, with families as members of the team. Family/
                                                        professional collaboration is key to best health outcomes. We strongly agree with the additional specifications that patients are ―supported in a nonjudgmental manner‖
                                                        which will allow for more collaboration as well as increased cultural competence.



Non-Member   Samuel Albrect,              Practice 12   Preferred Practice 12 (lines 811-829) states that healthcare home team members ―should work within the same plan of care and share responsibility for their                       No action taken. See response for previous comment
             Commission for Case                        contributions to the plan of care and achieving the patient’s goals.‖ The practice further highlights ―communication between the patient and care team‖ and the need for a
             Manager Certification                      ―specific time period to allow open discussion for questions and/or concerns.‖ As the need for communication is discussed, there is no mention of who will own the
                                                        primary communication role. We recommend that this role be assumed by a case manager/care coordinator, and should be described as such.
Non-Member   Ellen Kurtzman, The George Practice 13      • The term ―care partner‖ is not defined as part of this practice. It should be further specified.                                                                               Care partner is defined within the specifications of the practice.
             Washington University,                     • As an example of an implementation approach, the report refers to Planetree. Based on a literature review recently conducted to identify evidence-based models of
             Department of Nursing                      chronic disease, no scientific studies have demonstrated the Planetree as an effective model of care.
             Education                                  • Line 841 - ―accountable care organizations‖ do not currently exist but are merely a model under consideration. This practice suggests that ACOs exist and are able to
                                                        implement services.

Non-Member   Jan DeRoche, American        Practice 13   Clearly define care partner as an ―RN or SW case management professional, who meets individual state licensure requirements and holds appropriate certification in                No action taken. A particular professional is not singled out,
             Case Management                            clinical case management.‖                                                                                                                                                        reference is made to the entire healthcare team
             Association
Non-Member   Lauren Agoratus, Family      Practice 13   Preferred Practice #13 A program should be used that incorporates a care partner to support family and friends when caring for a hospitalized patient. We support the             No action necessary. Commentor appears to have misread
             Voices                                     notion of a care partner, particularly during hospitalization. For parents of children with special needs, we would suggest Parent-to-Parent as trained volunteer parents         specifications. The specifcations state the care partner should
                                                        matched to families of children with the same condition. We are concerned with the additional specification that the care partner should be from ―the accountable                 be a family member friend or volunter, friend or family member.
                                                        healthcare organization‖ as a potential conflict of interest and prefer a neutral party. We are extremely concerned that the care partner is untrained yet can provide
                                                        ―routine care‖ such as ―bathing…ambulation assistance-wheelchair use…monitoring fluids and medications…treatments-dressings…catheter drain and care…etc.‖.
                                                        These consist of medical care that needs to be done by professionals to avoid medical errors.

Member       Mary Naylor, University of   Practice 13    • The term ―care partner‖ is not defined as part of this practice. It should be further specified.                                                                               Care partner is defined within the specifications of the practice.
             Pennsylvania School of                     • As an example of an implementation approach, the report refers to Planetree. Based on a literature review recently conducted to identify evidence-based models of
             Nursing                                    chronic disease, no scientific studies have demonstrated the Planetree as an effective model of care.
                                                        • Line 841 - ―accountable care organizations‖ do not currently exist but are merely a model under consideration. This practice suggests that ACOs exist and are able to
                                                        implement services.

Non-Member   Ellen Kurtzman, The George Practice 14      • As stated (line 882), care coordination is referred to as a ―program‖---which it is not. Care coordination is an integrated function of care provision.                        Line 882 was incorporated in the draft report. The focus for this
             Washington University,                     • While assessment of provider satisfaction/perception of care is critical, this practice fails to acknowledge the need for patient and family satisfaction/perception of         practice was intended to come from a provider perspective.
             Department of Nursing                      care. Furthermore, it suggests that there is a single provider rather than a team of providers. Therefore, it should be modified to read: ―..the patient, family caregiver, and   Additional specification was added to include the perspective
             Education                                  providers’ perspectives of care coordination.‖                                                                                                                                    of the patient and family caregiver



Member       Ellen Schwalentocker,        Practice14    Since this practice addresses the providers perspective, the financial costs and resource burdens of care coordination activities should be evaluated from the providers          No action taken. Unsure of commentor's suggestion. The
             NACHRI                                     perspective. This information could be helpful in identifying best practices and policies, improving efficiencies and supporting the long-term viability of care coordination     practice is intended to assess the care coordination activities
                                                        activities and the healthcare home. Of course, the patient/family perspective also is vitally important.                                                                          from a providers perspective

Non-Member   Lauren Agoratus, Family      Practice 14   Preferred Practice #14 Assess and document the provider’s perspective of care coordination activities. We agree that the primary provider is key to the success of care Comment supported current draft report, no action necessary
             Voices                                     coordination.



Member       Mary Naylor, University of   Practice 14    • As stated (line 882), care coordination is referred to as a ―program‖---which it is not. Care coordination is an integrated function of care provision.                        Line 882 was incorporated in the draft report. The focus for this
             Pennsylvania School of                     • While assessment of provider satisfaction/perception of care is critical, this practice fails to acknowledge the need for patient and family satisfaction/perception of         practice was intended to from a provider perspective.
             Nursing                                    care. Furthermore, it suggests that there is a single provider rather than a team of providers. Therefore, it should be modified to read: ―..the patient, family caregiver, and   Additional specification was added to include the perspective
                                                        providers’ perspectives of care coordination.‖                                                                                                                                    of the patient and family caregiver

Member       Barbara Rudolph, The         Practice 15   This practice should be clarified to note that patients should have direct and timely access to key information, such as: diagnosis, medications, lab results, imaging            Committee suggests that the patient should have secured
             Leapfrog Group                             results, care summaries and care plans. This is already in practice in some large multispecialty clinics--they provide this type of summary at every visit. This could be         access to information that is the best and most appropriate to
                                                        readily measured in one question of a patient experience survey.                                                                                                                  guide care. Clarification has been made in report.


Member       Carol Sakala, Childbirth     Practice 15   With respect to the information system domain (practices 15-17), line 933 introducing this domain uses "integrated," whereas we recommend greater specificity in calling Comment incorporated into draft report
             Connection                                 for web applications and/or mobile applications (e.g., as for the iPhone platform). These consumer-facing technologies are the most likely ways that consumers and
                                                        patients will be able to access electronic health information, including information about care coordination We feel that EHRs and PHRs are only two examples of the
                                                        technology needed for care coordination.
Member       Carol Sakala, Childbirth     Practice 15   Please clarify within this practice that patients should have *direct* timely access to key information such as diagnoses, medications, lab results, care summaries, and Committee suggests that the patient should have secured
             Connection                                 care plans) without needing to go through caregivers and other health system gatekeepers who could pose access barriers. Further, we feel that there are in fact         access to information that is the best and most appropriate to
                                                        opportunities for measurement aligned with this practice in the area of patient experience and perhaps also in the are of care transitions.                              guide care. Clarification has been made in report.

Member       Christine Chen, Pacific      Practice 15   Information System Domain: In line 933 of the introduction to this domain, we have concerns about the use of the word ―integrated.‖ It should be clearly stated that the          Comment incorporated into report.
             Business Group on Health                   information systems used to assist with care coordination should include web applications and other mobile applications (such as those developed for an iPhone
                                                        platform). These are the most likely ways consumers and patients will be able to access electronic health information, and therefore the information systems
                                                        acknowledged as part of the Coordination of Care framework should not exclude those consumer-facing technologies. In general, EHRs and PHRs are only two
                                                        examples of the particular types of technology that are necessary for care coordination. Limiting discussion to only those two technologies will present a barrier for
                                                        effective use of HIT in care coordination.
Member       Christine Chen, Pacific      Practice 15   This practice needs to be clarified to note that patients should have direct, timely access (i.e., not only through a physician or other professional provider) to certain key    Committee suggests that the patient should have secured
             Business Group on Health                   health information, such as diagnoses, medications, lab results, care summaries and care plans). In addition, we do not agree that there are no opportunities for                 access to information that is the best and most appropriate to
                                                        measurement aligned with this practice. We would argue that patient experience of care measures and possibly the care transitions measures could be opportunities for             guide care. Clarification has been made in report.
                                                        measurement in this area.




Member       Debra Ness, National      Practice 15      We have concerns over the use of the word ―integrated‖ in line 933 of the introduction to this domain. It should be clearly stated that the information systems used to           Comment incorporated
             Partnership for Women and                  assist with care coordination should include web applications and other mobile applications (such as those developed for an iPhone platform). These are the most likely
             Families                                   ways consumers and patients will be able to access electronic health information, and therefore the information systems acknowledged as part of the Coordination of
                                                        Care framework should not exclude those consumer-facing technologies. In general, we are concerned by the prospect of limiting the discussion to only EHR and PHR
                                                        technologies, for that will create a barrier for effective use of HIT in care coordination.



Member       Debra Ness, National      Practice 15      On PP15, please clarify the language in this practice so that it is clear that patients should have direct, timely access (i.e., not only through a physician or other            Committee suggests that the patient should have secured
             Partnership for Women and                  professional provider) to certain key health information, such as diagnoses, medications, lab results, care summaries and care plans). In addition, please note that there        access to information that is the best and most appropriate to
             Families                                   are other opportunities for measurement aligned with this practice, including patient experience of care measures and possibly the care transitions measures.                     guide care. Clarification has been made in report.


Member       Ellen Schwalentocker,        Practice 15   Electronic information systems should include the functionalities appropriate and necessary to provide care for the specific population managed by the healthcare home. Committee suggests that the patient should have secured
             NACHRI                                     This may include any combination of infants, children, adolescents, adults, elderly, patients with chronic conditions, etc.                                             access to information that is the best and most appropriate to
                                                                                                                                                                                                                                guide care. Clarification has been made in report.

Member       Gayle Fortner, HC21          Practice 15   This practice needs to be clarified to note that patients should have direct, timely access (i.e., not only through a physician or other professional provider) to certain key    Committee suggests that the patient should have secured
                                                        health information, such as diagnoses, medications, lab results, care summaries and care plans). In addition, we do not agree that there are no opportunities for                 access to information that is the best and most appropriate to
                                                        measurement aligned with this practice. We would argue that patient experience of care measures and possibly the care transitions measures could be opportunities for             guide care. Clarification has been made in report.
                                                        measurement in this area.
Non-Member   Kay Jewell, Centers for      Practice 15   While availability of records is critical - it does not matter what the form if it is not read. Example: patient presents to ED, one which has electronic records of previous     Comment for which no action can be taken
             Consumers of Healthcare                    admissions and ED visits with full listing of known allergies. Patient is prescribed and nursing attempts to give the patient medication she is known to be allergic to,
                                                        patient objects and informs staff she is allergic. Staff return 2 more times with 2 different drugs also on the patient's allergy list. Patient expresses her frustration and
                                                        requests that staff review the record and list of allergies. She is told she is being "difficult".
Non-Member   Lauren Agoratus, Family      Practice 15   Preferred Practice #15 Standardized, integrated, and electronic information systems that have with functionalities essential to care coordination functions, decision             Comment supported current draft report, no action necessary
             Voices                                     support, and quality measurement and practice improvement should be used. Again, we support the concept of shared decision making and these systems are in place
                                                        utilizing programs such as Take Control of Your Health, or Health Dialog, as mentioned previously.

Member       Lee Anne Gardner,            Practice 15   This practice will be useful once standardization of EHR data elements and functionality requirements are in place.                                                               Comment supports draft report
             American College of
             Physicians, Performance
             Measurement
             Subcommittee

Member       Michelle Beauchesne,         Practice 15   Pediatric patients are at particular risk of not being central, because all children depend on surrogates for health care management and delivery (parents, grandparents,         No action taken.
             National Association of                    guardians, foster care system(s) state by state etc). Children usually cannot communicate well (or at all) themselves, yet have some fairly difficult concepts and needs
             Pediatric Nurse                            that require careful software design to incorporate into healthcare computer systems, that are not required by adult computer systems. (Spooner SA and the Council on
             Practitioners (NAPNAP)                     Clinical Information Technology. Clinical Report: Special Requirements of Electronic Health Record Systems in Pediatrics. Pediatr. 119:3:631-637) Information
                                                        technology that will work for children, will also work for adults. The converse is not true.


Member       Michelle Beauchesne,         Practice 15    Additionally, the criteria for evaluation of practices noted at the beginning of the document (p 10), refers to practices, which seemed to indicate a specific doctor's          No action taken. NQF defines a practice as a specific process
             National Association of                    individual businesses (e.g., Dr Smith and Jones Practice on Main Street). Later in the document, from context, the reference to practices seems to refer to care                  or manner of providing healthcare services or organization-
             Pediatric Nurse                            practices. Clinical information systems require a specific definition to separate the two concepts. The NQF should consider using the phrase care practices to clarify the        level activities that when executed effectively, leads to
             Practitioners (NAPNAP)                     intent throughout the document.                                                                                                                                                   improved outcomes.
Member       Michelle Beauchesne,         Practice 15   #15: Incorporate information systems with functionalities essential to care coordination, decision support, and quality measurement. NAPNAP along with the AAP                    No action taken. The intention of health information systems
             National Association of                    suggest that this practice include functionalities that a health information system must have to support children's core needs. (Spooner, op cit.)                                are to be applicable to all patients including children
             Pediatric Nurse
             Practitioners (NAPNAP)

Member       Carol Sakala, Childbirth     Practice 16   Effective care coordination will require adequate information and support at home. Thus, please specify that electronic health record systems will provide caregivers in          No action taken. Practice clearly states "all points of care."
             Connection                                 home settings with access to patient health data.

Member       Christine Chen, Pacific      Practice 16   Care coordination is not possible without providing adequate information and support at home. Therefore it should be explicitly stated that electronic record systems             No action taken. Practice clearly states "all points of care."
             Business Group on Health                   should allow the patient’s health data to be accessible to caregivers in the home, whether that be through a patient portal or through linkages with other technologies
                                                        being used in the home.

Member       Christine Chen, Pacific      Practice 16    In terms of the additional specifications for this practice, we are concerned by the language in line 1025 stating that access to patient information should occur through       Clarification provided in report related to data exchange.
             Business Group on Health                   one single data exchange. This needs to be clarified, because as stated in this report it seems overly prescriptive. If it does refer to a single database, it has significant
                                                        negative implications for privacy and security.


Member       Debra Ness, National      Practice 16      Information and support must be accessible by patients in their home setting in order for care coordination to be most effective. Therefore it should be explicitly stated        No action taken. Practice clearly states "all points of care."
             Partnership for Women and                  that electronic record systems should allow the patient’s health data to be accessible to caregivers in the home, whether that be through a patient portal or through
             Families                                   linkages with other technologies being used in the home.

Non-Member   Ellen Kurtzman, The George Practice 16     • In addition to caregivers at all points of care (line 996-997), patient’s health status should be accessible to patients and their designees. Additionally, as written, this    no action taken. Practice 11 refers to health information
             Washington University,                     practice is inconsistent with practice 11.                                                                                                                                        whereas practice 16 (line 996-997) refers to health data. Is
             Department of Nursing                                                                                                                                                                                                        health information the same as health data. Wording was
             Education                                                                                                                                                                                                                    changed in report to be consistent
Member       Ellen Schwalentocker,      Practice 16     Health information systems are not all equal in meeting the healthcare and care coordination demands of all patient groups. Line 1012 might read, Electronic health               No action taken
             NACHRI                                     records should be certified as to conformance with national standards appropriate for the specific patient population cared for within the particular healthcare home.


Member       Gayle Fortner, HC21          Practice 16   Care coordination is not possible without providing adequate information and support at home. Therefore it should be explicitly stated that electronic record systems             No action taken. Practice clearly states "all points of care."
                                                        should allow the patient’s health data to be accessible to caregivers in the home, whether that be through a patient portal or through linkages with other technologies
                                                        being used in the home.




                                                                                                                       NQF DRAFT: DO NOT CITE, QUOTE, REPRODUCE, OR CIRCULATE                                                                                                                                  15
Member       Barbara Rudolph, The          General       The Leapfrog Group supports the National Quality Forum's efforts to address the lack of care coordination evident in our current healthcare delivery environment. The      Comment for which no action can be taken. NQF recognizes
             Leapfrog Group                              Leapfrog Group also supports the effort to develop a comprehensive framework for care coordination measurement. However, the devil is in the details, in particular, the the importance of outcome measures and other NQF projects
                                                         use of terminology that is limiting in terms of application of these metrics. We hope that the National Quality Forum would broaden these preferred practices to all       are currently addressing this issue
                                                         licensed healthcare providers who are delivering "primary care" to patients. In addition, we hope that NQF will quickly address the need for linkage of these practices to
                                                         the outcomes of care. We would like NQF to avoid the same journey through process measures that has occurred with hospital and physician measures.


Member       Gayle Fortner, HC21           Practice 16   In terms of the additional specifications for this practice, I am concerned by the language in line 1025 stating that access to patient information should occur through one Clarification provided in report related to data exchange.
                                                         single data exchange. This needs to be clarified, because as stated in this report it seems overly prescriptive. If it does refer to a single database, it has significant
                                                         negative implications for privacy and security.


Non-Member   Lauren Agoratus, Family       Practice 16    Preferred Practice #16 An electronic record system should allow the patient’s health data to be accessible to caregivers at all points of care. We support accessibility to Comment supported current draft report, no action necessary
             Voices                                      the health record, which should include accessibility to the patient and/or their family caregiver as appropriate. Under additional specifications, we agree that the EHR
                                                         (Electronic Health Record) ―should conform to national standards‖ for consistency and ease of measuring outcomes.


Member       Lee Anne Gardner,             Practice 16   This comment applies to this practice and practice 17. HIPPA issues about sharing data will need to be addressed.                                                                  Comment incorporated. The specification from Practice 15
             American College of                                                                                                                                                                                                            was used: "Information systems should comply with all HIPAA
             Physicians, Performance                                                                                                                                                                                                        privacy, security rules, and state laws related to privacy of
             Measurement                                                                                                                                                                                                                    health informaiton."
Member       Subcommittee
             Mary Naylor, University of    Practice 16   • In addition to caregivers at all points of care (line 996-997), patient’s health status should be accessible to patients and their designees. Additionally, as written, this     No action taken. Practice 11 refers to health information
             Pennsylvania School of                      practice is inconsistent with practice 11.                                                                                                                                         whereas practice 16 (line 996-997) refers to health data. Is
             Nursing                                                                                                                                                                                                                        health information the same as health data. Wording was
                                                                                                                                                                                                                                            changed in report to be consistent

Member       Michelle Beauchesne,          Practice 16   #16: Caregiver access to electronic record system. The inclusion of advance directives in this practice may not be appropriate for pediatrics. NAPNAP along with the               No action taken
             National Association of                     AAP suggest that this practice be limited to adults.
             Pediatric Nurse
             Practitioners (NAPNAP)

Member       Robert Plovnick, American     Practice 16   Patients’ preferences over how their information is shared will vary. There is a concern that patients may withhold sensitive information or otherwise avoid care if privacy Comment incorporated into draft report
             Psychiatric Association for                 in an electronic environment cannot be assured. The description of this practice should include a statement like that in Practice 17 (lines 1025-1026); that an electronic
             Research and Education                      health record system should allow patients’ health data to be accessible to caregivers at all points of care, while still providing for the privacy of sensitive information.


Member       Barbara Rudolph, The          Practice 17   In regard to the patient's access to their electronic medical records or personal health records or "community records", the patient should not be required to go through a Changes were incorporated into the draft report, accessability
             Leapfrog Group                              Regional Exchange--in fact, the Regional Exchange should not be seen as the "keeper of access for patients" or "as one large medical record." The electronic medical        of patient information through a regional helath information
                                                         record should reside with the provider of care, and the provider of care should provide reasonable access to the patient through a patient portal or upon request. The      system, should only be applicable for the healthcare teams
                                                         Regional Exchange allows provider's access to other key information for care planning and inclusion in their record, with the patient's permission for access. This is what
                                                         fits with most state statutes in regard to personal health information.

Member       Debra Ness, National      Practice 17       In terms of the additional specifications for this practice, we are concerned by the language in line 1025 stating that access to patient information should occur through         Clarification provided in report related to data exchange.
             Partnership for Women and                   one single data exchange. This needs to be clarified, because as stated in this report it seems overly prescriptive. If it does refer to a single database, it has significant
             Families                                    negative implications for privacy and security.

Non-Member   Ellen Kurtzman, The George Practice 17      Why is this practice limited to regional information exchanges? Information sharing must occur at multiple levels including but not limited to regional information                No action taken. The Committee intended for this practice to
             Washington University,                      exchanges.                                                                                                                                                                         foster information sharing, but the use will be governed by
             Department of Nursing                                                                                                                                                                                                          regional information exchange systems
             Education
Non-Member   Lauren Agoratus, Family       Practice 17    Preferred Practice #17 Regional health information systems governed by public/private partnerships should enable healthcare home teams and patients and their                     Comment supported current draft, no action necessary
             Voices                                      designees to access all patient information. We support the use of health information systems and would suggest perhaps county based data for access to community
                                                         supports and a statewide overview system for consistency

Member       Mary Naylor, University of    Practice 17   Why is this practice limited to regional information exchanges? Information sharing must occur at multiple levels including but not limited to regional information                No action taken. The Committee intended for this practice to
             Pennsylvania School of                      exchanges.                                                                                                                                                                         foster information sharing, but the use will be governed by
             Nursing                                                                                                                                                                                                                        regional information exchange systems

Non-Member   Samuel Albrect,               Practice 17   Preferred Practice 17 (lines 1070-1081) cites a policy statement by the American College of Physicians, Society of Hospital Medicine, et al, which identifies several        No action taken. The Committee chose not to single out a
             Commission for Case                         principles to address the quality gaps in transitions between inpatient and outpatient settings. These principles include accountability, timely interchange of information, particular professional for any of the practices.
             Manager Certification                       involvement of the patient and family members, and standardized metrics to lead to quality improvement and accountability. The CCMC maintains that the individual with
                                                         primary accountability and responsibility for communication and exchange of information is a case manager/care coordinator. Accrediting bodies such as URAC,
                                                         JCAHO, and NCQA have standards that address the practice of case management and the qualifications of individuals practicing case management, including
                                                         certification. We recommend that Preferred Practice 17 be modified to specifically designate an individual with responsibility for communication and information
                                                         exchange and that individual be a case manager/care coordinator.

Member       Carol Sakala, Childbirth      Practice 18   Further, we express concern about the language in line 1025 specifying that access to patient information occur through a single data exchange. This may be overly                 Clarification provided in report related to data exchange.
             Connection                                  prescriptive, and a single database has significant negative implications for privacy and security of the data.




Member       Carol Sakala, Childbirth      Practice 18   Appropriate follow-up protocols are needed to ensure that the consumer/patient and designees understand and endorse the care plan. We support the concept of shared Comment supports draft report
             Connection                                  decision making, which may be especially crucial during care transitions.


Member       Christine Chen, Pacific       Practice 18   Appropriate follow-up protocols should be used to assure timely understanding and endorsement of the plan for patient and their designees. We agree that decision-                 Comment for which no action can be taken
             Business Group on Health                    making should be shared, especially during transitions to different types of care.


Member       Ellen Schwalentocker,         Practice 18   It is important that this Practice emphasize allowing sufficient lead time in planning a significant transition such as the life transition from adolescence to adulthood. This    No action taken. The practices under the Transitions domain
             NACHRI                                      transition is particularly difficult for adolescents with congenital conditions as too few adult providers are knowledgeable and comfortable managing these conditions.            are to be applicable for transitions from different care settings
                                                                                                                                                                                                                                            and providers, which would include 'life transitions'



Member       Gayle Fortner, HC21           Practice 18   Appropriate follow-up protocols should be used to assure timely understanding and endorsement of the plan for patient and their designees. I agree that decision-making Comment for which no action can be taken
                                                         should be shared, especially during transitions to different types of care.
Non-Member   Lauren Agoratus, Family       Practice 18   Preferred Practice #18 Decisionmaking and planning for transitions of care should involve the patient, and, according to patient preferences, family and                Comment incorporated into draft report
             Voices                                      caregivers(including the healthcare home team). Appropriate follow-up protocols should be used to assure timely understanding and endorsement of the plan for patient
                                                         and their designees. Under additional specifications we agree that all resources should be ―in the patient’s primary written and spoken language.‖ This should include
                                                         ASL (American Sign Language) when necessary as well as the realization that the written/spoken language may also be two different languages.


Non-Member   Lauren Agoratus, Family       Practice 18   Preferred Practice #18 Decisionmaking and planning for transitions of care should involve the patient, and, according to patient preferences, family and                  No action taken. The practices under the Transitions domain
             Voices                                      caregivers(including the healthcare home team). Appropriate follow-up protocols should be used to assure timely understanding and endorsement of the plan for patient are to be applicable for transitions from different care settings
                                                         and their designees. We agree that decision-making should be shared, especially during transitions to different types of care. However, care must be taken in the area of and providers, which would include 'life transitions'
                                                         mental health in accordance in certain states with regard to minor consent for mental health treatment as well as involuntary commitment laws.

Non-Member   Lauren Agoratus, Family       Practice 18   We noted in the introduction that ―one in five patients discharged…experience an adverse event…more than half…are drug-related.‖ We would suggest training of                      No action necessary. NQF has a portfolio dedicated to
             Voices                                      patients or their caregivers on medication administration and preventing errors prior to discharge. Further, the other ―half‖ needs to be studied to determine if the adverse      adverse events, patient safety and medication
                                                         event was preventable and due to premature hospital discharge.
Member       Michelle Beauchesne,          Practice 18   #18: Patient, family, and caregiver input in decision-making. This practice should include clear language on life transitions, including the need for anticipatory planning that   No action taken. The practices under the Transitions domain
             National Association of                     may need to begin years ahead of the actual transfer of care (e.g., the life transition from adolescence to adulthood).                                                            are to be applicable for transitions from different care settings
             Pediatric Nurse                                                                                                                                                                                                                and providers, which would include 'life transitions'
             Practitioners (NAPNAP)
Non-Member   Samuel Albrect,               Practice 18   Preferred Practice 18 (lines1094-1112) addresses the health care home team in meeting the needs of patients and their designees in planning, decision making, and                  No action taken. No one individual was specificed to have the
             Commission for Case                         transitions of care. As stated on line 1100: ―Healthcare home team has current information and resources that assist the patient and their designees in making the best            lead, the practice refers to the healthcare team.
             Manager Certification                       decisions about transitions, especially for post acute care or long term care.‖ What is missing in this discussion is the importance of having a case manager/care
                                                         coordinator who can own that process and ensure that protocols are followed and services are delivered as needed. We recommend that Preferred Practice 18 be
                                                         modified to specifically designate an individual with responsibility to own this transition process and that individual be a case manager/care coordinator.

Member       Ellen Schwalentocker,         Practice 19   We suggest that readmission measures are a very blunt assessment of patient and caregiver preparation for ongoing care. More direct evaluation of caregiver                        Comment incorporated into report
             NACHRI                                      participation and knowledge would be helpful.
Member       Katherine Kany, AFT           Practice 19   "Patient and their designees should participate directly in determining and preparing for ongoing care during and after transitions." Just to clarify what may already be          No action taken. Practice includes preparing for --i.e., in
             Healthcare                                  assumed, planning should begin with patients and designees in advance to manage needs during and after transitions.                                                                advance.

Non-Member   Lauren Agoratus, Family       Practice 19   Preferred Practice #19 Patient and their designees should participate directly in determining and preparing for ongoing care during and after transitions. We agree that           Comment supported current draft report, no action necessary
             Voices                                      preparation is extremely important, particularly during transition to care, and must involve the patent and their designees, such as family caregivers, as appropriate.
                                                         Under additional specifications, we agree with patient/caregiver education on medication is needed as stated above in the introductory section.

Member       Lee Anne Gardner,             Practice 19   This comment directly addresses the measures identified to evaluate this practice. Readmission measures directly evaluate outcomes of care that are attributable to                We recognize that some measures identified are indirect
             American College of                         providers. These measures indirectly evaluate patient engagement or preparation for on going care.                                                                                 measures, but these endorsed serve as starting points for
             Physicians, Performance                                                                                                                                                                                                        organizations to be considered.
             Measurement
Member       Lee Anne Gardner,             Practice 19   A better approach to measure this practice would be measures that directly evaluate programs, forms or other related activities to evaluate patient preparation and                Comment incorporated.
             American College of                         engagement for on going care.
             Physicians, Performance
             Measurement
             Subcommittee
Non-member   Ellen Kurtzman, The George Practice 20      • Practice 20 has demonstrated effectiveness among low risk populations (limited to 1 diagnosis) and should be portrayed this way                                                  No action taken. The practices are intented to be applicable to
             Washington University,                                                                                                                                                                                                         multiple patient populations. Specific comment will be referred
             Department of Nursing                                                                                                                                                                                                          to practice developer for informational purposes.
             Education

Member       Ellen Schwalentocker,         Practice 20   To our knowledge, systematic care transitions programs are primarily designed for situations with one primary diagnosis such as post-MI or heart failure. Until                    No action taken. Practice statement indicates this practice
             NACHRI                                      experience with this model increases, the wording of the Practice might read should be used whenever appropriate and available.                                                    should be used whenever available


Non-Member   Jan DeRoche, American         Practice 20   Add - "Care transitions programs will be developed under the direction of an RN or SW case manger in collaboration with patients, caregivers and members of the                    No action taken. A particular professional is not singled out,
             Case Management                             healthcare team. A Care transitions coach is either a licensed RN or SW case manager or works under the direction of a licensed RN or SW case manager."                            reference is made to the entire healthcare team
             Association
Member       Lee Anne Gardner,             Practice 20   We are not sure about the ability to engage in self management coaching during the 4 week transitional period.                                                                     The specifications and evidence base were provided by the
             American College of                                                                                                                                                                                                            developer. Comment will be referred for consideration.
             Physicians, Performance
             Measurement
             Subcommittee

Member       Mary Naylor, University of    Practice 20   • Practice 20 has demonstrated effectiveness among low risk populations (limited to 1 diagnosis) and should be portrayed this way                                                  No action taken. The practices are intented to be applicable to
             Pennsylvania School of                                                                                                                                                                                                         multiple patient populations. Specific comment will be referred
             Nursing                                                                                                                                                                                                                        to practice developer for informational purposes.


Member       Rita Munley Gallagher,        Practice 20   Page 46: Continuity of medical care between the hospital and primary care physicians [sic] facilitated by the TCN accompanying patient at least for the first follow-up            The specifications and evidence base were provided by the
             American Nurses                             visits;...In order to increase the salience of the practices and measures, the American Nurses Association respectfully requests the substitution of the more inclusive            developer. Comment will be referred for consideration.
             Association                                 verbiage ―clinician‖ for ―physician‖, as appropriate, throughout the document.


Non-Member   Samuel Albrect,               Practice 20    Preferred Practice 20 (lines 1169-1174) discusses the role of a ―care transitions coach‖ to provide additional support. The transition coach, as described, assists in    Appropriate clarification of the care transitions coach has been
             Commission for Case                         learning and developing care transitions self-management skills. The language does not define the qualifications of the transitions coach; for example whether this person incorporated into draft report.
             Manager Certification                       should be a licensed, certified professional or a community worker or even a volunteer. We recommend that the NQF Preferred Practice 20 language stipulate that this
                                                         person be a qualified healthcare professional, such as a certified case manager. Otherwise, this language could be misconstrued or misinterpreted.

Non-Member   Sandra Lowery, CCMI           Practice 20   Line 1162 The focus should not be exclusive to medications; it should also include all treatment and activities of daily living.                                                   The practice developer identified four key areas for
             Associates                                                                                                                                                                                                                     implementation. The evidence supports the practice as written


Non-member   Ellen Kurtzman, The George Practice 21       • Practice 21 has demonstrated effectiveness among high risk populations (four or more diagnoses) and should be portrayed this way                                                Comment incorporated into draft report
             Washington University,                      • Transitional Care Model is a particular evidence-based model of care. Grammatically, the practice should be reworded: ―The Transitional Care Model should be
             Department of Nursing                       deployed….‖
             Education                                   • As an example of an implementation approach, the University of Pennsylvania’s Health System has implemented TCM.



                                                                                                                        NQF DRAFT: DO NOT CITE, QUOTE, REPRODUCE, OR CIRCULATE                                                                                                                                  16
Member       Barbara Rudolph, The         General        The Leapfrog Group supports the National Quality Forum's efforts to address the lack of care coordination evident in our current healthcare delivery environment. The      Comment for which no action can be taken. NQF recognizes
             Leapfrog Group                              Leapfrog Group also supports the effort to develop a comprehensive framework for care coordination measurement. However, the devil is in the details, in particular, the the importance of outcome measures and other NQF projects
                                                         use of terminology that is limiting in terms of application of these metrics. We hope that the National Quality Forum would broaden these preferred practices to all       are currently addressing this issue
                                                         licensed healthcare providers who are delivering "primary care" to patients. In addition, we hope that NQF will quickly address the need for linkage of these practices to
                                                         the outcomes of care. We would like NQF to avoid the same journey through process measures that has occurred with hospital and physician measures.


Member       Ellen Schwalentocker,        Practice 21    Could this practice be generalized to other populations?                                                                                                                        No action taken. This practice can be generalized for other
             NACHRI                                                                                                                                                                                                                      populations

Non-Member   Jan DeRoche, American        Practice 21    Clearly define the role and qualifications for the transitional care nurse with the following language - "A transitional care RN or Social worker is defined as a licensed RN   No action taken. A particular professional is not singled out,
             Case Management                             or SW case management professional, preferably certified in case management."                                                                                                   reference is made to the entire healthcare team
             Association



Non-Member   Jan DeRoche, American        Practice 21    We recommend adding the following clarification to the TCN role - "TCN/SW or Inpatient case managers." Line 1231: "TCN/SW accompanies the patient… if needed."                  No action taken. A particular professional is not singled out,
             Case Management                                                                                                                                                                                                             reference is made to the entire healthcare team
             Association
Non-Member   Jan DeRoche, American        Practice 21    Provide clear explanation that the transition care nurse/social worker role is not intended to replace that of the home health nurse. Clearly define the caseload for this      No action taken. Comment is be passed on to the practice
             Case Management                             position.                                                                                                                                                                       developer for further evaluaiton
             Association
Non-Member   Kay Jewell, Centers for      Practice 21    This is a very important practice. Information on the patient's baseline functional status and cognitive function as well as documentation of their status at admission is      Comment supports draft report
             Consumers of Healthcare                     important to the process of care and to the patient and their family. it is important for the hospital team to recognize any decline and subsequent improvement or
                                                         continued decline throughout the hospitalization process because of its relationship to successful discharges and discharge status.

Non-Member   Lauren Agoratus, Family      Practice 21    Preferred Practice #21 A Transitional Care Model should be deployed for chronically high-risk older adults. We support the idea of a model of care but would expand this Comment supported current draft report, no action necessary
             Voices                                      to include anyone with a chronic condition who is at high risk, not just ―older adults‖. Under additional specifications, we agree that there needs to be a ―holistic focus‖ and
                                                         not just the particular condition as comorbidities can increase complications. We support the follow-up, particularly after discharge, of ―24-28 hours‖, ―weekly during the
                                                         first month‖ etc. We support the transitional care nurse (TCN) telephone availability during extended hours (8 a.m.-8p.m. and some weekend hours) and an emergency
                                                         care plan if the TCN is unavailable.
Member       Lee Anne Gardner,            Practice 21    "A Transitional Care Model should be deployed for chronically high-risk older adults" practice suffers from the same problem as practice 19. Readmission measures do Comment incorporated
             American College of                         not evaluate the presence or absence of a transitional care model. Readmission measures assess the impact of outcomes for patients with or without a transitional care
             Physicians, Performance                     model. Measures directly assessing transitional care models coupled with a readmission measure would be useful if this practice is turned into a performance measure.
             Measurement
             Subcommittee
Member       Mary Naylor, University of   Practice 21     • Practice 21 has demonstrated effectiveness among high risk populations (four or more diagnoses) and should be portrayed this way                                             Comment incorporated into draft report
             Pennsylvania School of                      • Transitional Care Model is a particular evidence-based model of care. Grammatically, the practice should be reworded: ―The Transitional Care Model should be
             Nursing                                     deployed….‖
                                                         • As an example of an implementation approach, the University of Pennsylvania’s Health System has implemented TCM.

Member       Nancy Foster, American       Practice 21    (AHA 1 of 2) Practice #21 states that a Transitional Care Model, including a Transitional Care Nurse, should be used to coordinate care when a patient with ongoing             Comment for which no action can be taken
             Hospital Association                        care needs is discharged from a hospital stay back to his or her community. Through extensive research, the Transitional Care Model has proven to be a successful
                                                         approach to coordinating the care needs of complex patients, and the results achieved by the model should be commended. We know, however, that there are various
                                                         projects being tested and developed in hospitals and communities that may employ slightly different intervention strategies, or utilize different types of providers, and
                                                         that are also achieving successful results. For example, some programs use pharmacists to follow up with patients and their medication needs after discharge. Some
                                                         programs focus intensively on preparing the patient for successful self-care management before the patient is discharged, with less extensive follow-up once the patient
                                                         is back in the community.


Member       Nancy Foster, American       Practice 21    (AHA 2 of 2) We expect the NQF's preferred practices to stand as a guiding document for at least several years. During that time, it is likely that the science around          The specifications and evidence base were provided by the
             Hospital Association                        successful care transitions will continue to grow as more research is conducted and more projects are completed. We believe that the scope of preferred practice #21            developer. Comment will be referred for consideration.
                                                         should be broadened to recognize the likelihood that continued work in this area will lead to other well-developed care models, and that, as the evidence grows, the
                                                         adoption of one or more of these different models may be appropriate for different organizations.


Non-Member   Samuel Albrect,              Practice 21    Preferred Practice 21 (lines 1185-1195) describes a Transitional Care Model for chronically high-risk older adults, and references a ―Transitional Care Nurse‖ to be the        Evidence supporting the practice specifically calls for a
             Commission for Case                         primary coordinator of care. The CCMC observes that the role of the Transitional Care Nurse as described here is essentially the same as that of a case manager/care            transitional care nurse
             Manager Certification                       coordinator. We also note that this is the only place in the entire document that a case management role is specifically described, although the title given here is
                                                         transitional care nurse. We recommend that the role and function of care coordination in the NQF Preferred Practices Consensus Standards be designated to case
                                                         managers.

Non-Member   Sandra Lowery, CCMI          Practice 21    Lines 1192-1199 Why just focus on hospitals? I recommend you consider the community, i.e. all settings.                                                                         The evidence supports the practice as written
             Associates

Member       Sheree Chin Ledwell, Aetna Practice 21      Practice Statement #21 regarding a ―Transitional Care Model‖ should not be limited to just ―older adults,‖ but for all those that are chronically ill and at high risk.         The evidence base for this practice is well supported with the
                                                                                                                                                                                                                                         current model. Comment forwarded to practice developer.


Non-Member   Terry Kelley, Hill Physicians Practice 21   This section addresses onsite visits and communication with TCNs. Our reality in healthcare delivery is that resources for onsite contact are very limited and should be        The evidence base for this practice is well supported with the
             Medical Group                               utililzed for patients with specific criteria. I have been doing telephonic case management both in an IPA and Health Plan for many years, able to assess, plan, implement current model of having a transitional care nurse. Comment
                                                         a care plan with appropriate interventions to barriers for the large majority of members. We are able to achieve the pt. centered goals. We chose to make onsites for           forwarded to practice developer
                                                         specific compicated coordination cases. It is effective.
                                                         My concern is that if onsite is mandated vs. choice of telephonic vs. onsite, the cost of health care will increase. In addition, there are very limited resources of qualified
                                                         licensed personnel to perform these functions. If emphasis is placed on the goals, the process (which is well articulated here) than how it is done should be structured to
                                                         support those goals. CMSA (I am on the national board) has created a Model Law Act to identify the process of case management along with how it can be done and by
                                                         whom in order to meet measurable quality standards.
                                                         So, in conclusion, do not limit assessments and interventions to inperson but be open to supporting the process with telephonic as appropriate.
                                                         Thank you for you time and the opportunity to comment



Member       Carol Sakala, Childbirth     Practice 22    We feel that health care organizations should develop and implement a standardized communication template for transitions of care. This should include a minimal set of Comment supports draft report
             Connection                                  core data elements that are accessible to consumers/patients and their designees. We agree that standardization for communication will facilitate care coordination,
                                                         patent-provider communication, outcome measurement. We concur that opportunities for measurement include "medication errors, hospital admission and readmission."



Member       Christine Chen, Pacific      Practice 22    Healthcare organizations should develop and implement a standardized communication template for the transitions of care process, including a minimal set of core data Comment supports draft report
             Business Group on Health                    elements that are accessible to the patient and their designee during care. We agree that standardization for communication will help facilitate care coordination,
                                                         patient/provider communication, and measurement of outcomes. We agree that opportunities for measurement include ―medication errors, hospital admission and
                                                         readmission‖.


Member       Debra Ness, National      Practice 22       Healthcare organizations should develop and implement a standardized communication template to guide the process of care transitions. The core set of data elements Comment supports draft report
             Partnership for Women and                   should be standardized for communication in order to facilitate care coordination, patient/provider communication, and measurement of outcomes. We agree that
             Families                                    opportunities for measurement include ―medication errors, hospital admission and readmission‖.

Non-member   Ellen Kurtzman, The George Practice 22      • This practice is not well specified. The term ―communication template‖ is not defined. The practice should be better specified or excluded from those recommended.            No action taken. The specifications clearly delineate the
             Washington University,                                                                                                                                                                                                      important components
             Department of Nursing
             Education
Member       Ellen Schwalentocker,        Practice 22    We agree with the recommendation by AAP and NAPNAP that the practice should specify that the standardized communication template is inclusive to transfers of care No action taken. The practices under the Transitions domain
             NACHRI                                      resulting from life transitions.                                                                                                                                   are to be applicable for transitions from different care settings
                                                                                                                                                                                                                            and providers, which would include 'life transitions'



Member       Gayle Fortner, HC21          Practice 22    Healthcare organizations should develop and implement a standardized communication template for the transitions of care process, including a minimal set of core data Comment supports draft report
                                                         elements that are accessible to the patient and their designee during care. We agree that standardization for communication will help facilitate care coordination,
                                                         patient/provider communication, and measurement of outcomes. We agree that opportunities for measurement include ―medication errors, hospital admission and
                                                         readmission‖.


Non-Member   Lauren Agoratus, Family      Practice 22    Preferred Practice #22 Healthcare organizations should develop and implement a standardized communication template for the transitions of care process, including a             Comment supports draft report, no action necessary
             Voices                                      minimal set of core data elements that are accessible to the patient and their designee during care. We agree that standardization for communication will help facilitate
                                                         care coordination, patient/provider communication, and measurement of outcomes. We agree that opportunities for measurement include ―medication errors, hospital
                                                         admission and readmission‖.


Member       Mary Naylor, University of   Practice 22    • This practice is not well specified. The term ―communication template‖ is not defined. The practice should be better specified or excluded from those recommended.            No action taken. The specifications clearly delineate the
             Pennsylvania School of                                                                                                                                                                                                      important components
             Nursing

Member       Michelle Beauchesne,         Practice 22    # 22: Standardized communication template for care transitions. The practice should specify that the standardized communication template is inclusive to transfers of           No action taken. The practices under the Transitions domain
             National Association of                     care resulting from life transitions.                                                                                                                                           are to be applicable for transitions from different care settings
             Pediatric Nurse                                                                                                                                                                                                             and providers, which would include 'life transitions'
             Practitioners (NAPNAP)


Member       Sheree Chin Ledwell, Aetna Practice 22      Practice Statement #22 – A ―standardized communication template‖ should also have the flexibility to be tailored or unique to the individual. It is their own "health record" No action taken. Unclear how to address comment because it
                                                         that is transportable. However, we agree that standardized communications will promote care coordination.                                                                     argues for flexibility, but also agrees standardization promotes
                                                                                                                                                                                                                                       care coordination.



Non-member   Ellen Kurtzman, The George Practice 23      • As written (line 1318) it is too limited. Management of symptoms beyond those that are clinical should be incorporated into this practice.                                    Commentor unclear as to what constitutes a symptom that is
             Washington University,                                                                                                                                                                                                      not clinical
             Department of Nursing
             Education
Member       Ellen Schwalentocker,      Practice 23      As previously stated, more patient-centric measures, such as assessment of condition status, level of control, functional status compared to previous periods, etc.,            Comment incorporated into report
             NACHRI                                      rather than blunt measures (e.g., readmissions) may be opportunities for measurement.


Non-Member   Jan DeRoche, American        Practice 23    Insert - ―The standardized communication template and core data elements will be determined by an interdisciplinary team of experts.‖ We request that this team of              No action taken. The team of experts references all
             Case Management                             experts include representatives of the American Case Management Association.                                                                                                    professionals and does not sinlge out a particular group
             Association


Member       Katherine Kany, AFT          Practice 23    Healthcare providers and healthcare organizations should implement protocols/policies for a standardized approach to all transitions of care. Policies and procedures           No action taken. The focus of this practice is on
             Healthcare                                  related to transitions and the critical aspects should be included in the standardized approach." Again, to clarify what may be assumed, healthcare providers and               standarization.
                                                         healthcare organizations should implement evidence-based protocols/policies for a standardized approach to all transitions of care.

Non-Member   Lauren Agoratus, Family      Practice 23    Preferred Practice #23 Healthcare providers and healthcare organizations should implement protocols/policies for a standardized approach to all transitions of care.            Comment supported current draft, no action necessary
             Voices                                      Policies and procedures related to transitions and the critical aspects should be included in the standardized approach. We support implementation of transition policies
                                                         again for standardization, ease of communication, and outcome measurement.


Member       Mary Naylor, University of   Practice 23    • As written (line 1318) it is too limited. Management of symptoms beyond those that are clinical should be incorporated into this practice.                                    Commentor unclear as to what constitutes a symptom that is
             Pennsylvania School of                                                                                                                                                                                                      not clinical
             Nursing

Member       Michelle Beauchesne,         Practice 23    Please specifically include the phrase, "and for chronically high-risk ex-NICU patients."                                                                                       Comment incorporated into report.
             National Association of
             Pediatric Nurse
             Practitioners (NAPNAP)

Member       Katherine Kany, AFT          Practice 24    "Healthcare providers and healthcare organizations should have systems in place to clarify, identify, and enhance mutual accountability (complete/confirmed                     No action taken. The Committee did not feel it should specify
             Healthcare                                  communication loop) of each party involved in a transition of care."                                                                                                            professional expertise. A separate practice does exist based
                                                         Healthcare providers and organizations should have a single point of management in place to clarify, identify and enhance the transition process. These care managers           on the Naylor model (Practice 21).
                                                         should be nurse practitioners or social workers who see the patient and family during acute episodes, at discharge, and in the home (based on the Transitional Care
                                                         Model by Mary Naylor).




                                                                                                                        NQF DRAFT: DO NOT CITE, QUOTE, REPRODUCE, OR CIRCULATE                                                                                                                               17
Member       Barbara Rudolph, The         General       The Leapfrog Group supports the National Quality Forum's efforts to address the lack of care coordination evident in our current healthcare delivery environment. The      Comment for which no action can be taken. NQF recognizes
             Leapfrog Group                             Leapfrog Group also supports the effort to develop a comprehensive framework for care coordination measurement. However, the devil is in the details, in particular, the the importance of outcome measures and other NQF projects
                                                        use of terminology that is limiting in terms of application of these metrics. We hope that the National Quality Forum would broaden these preferred practices to all       are currently addressing this issue
                                                        licensed healthcare providers who are delivering "primary care" to patients. In addition, we hope that NQF will quickly address the need for linkage of these practices to
                                                        the outcomes of care. We would like NQF to avoid the same journey through process measures that has occurred with hospital and physician measures.


Non-Member   Lauren Agoratus, Family      Practice 24   Preferred Practice #24 Healthcare providers and healthcare organizations should have systems in place to clarify, identify, and enhance mutual accountability              Comment supported current draft report, no action necessary
             Voices                                     (complete/confirmed communication loop) of each party involved in a transition of care. We also agree that this will enhance standardization in communication, shared
                                                        responsibility, and essential follow-up.



Member       Sheree Chin Ledwell, Aetna Practice 24     Practice Statement #24 - " Healthcare providers and healthcare organizations should have systems in place to clarify, identify, and enhance mutual accountability, "     No action taken. Specification 2 states, "documented receipt
                                                        should include documented receipt of communications with identification of roles for providers, e.g. conference calls or rounding with pertinent providers and member as of information should be provided."
                                                        appropriate to discuss progress, needed interventions.



Member       Carol Sakala, Childbirth     Practice 25   Health care organizations should evaluate the effectiveness of both transition policies and protocols and transition outcomes. We underscore the significance of           Comment supports draft report
             Connection                                 measuring and reporting adverse events, especially as they might result from poor care coordination, at the earliest possible opportunity.


Member       Christine Chen, Pacific      Practice 25   Healthcare organizations should evaluate the effectiveness of transition protocols and policies, as well as evaluate transition outcomes. We concur that evaluation is key Comment supports draft report
             Business Group on Health                   to improving health outcomes. Under additional specifications, we support the evaluation of adverse events, especially as they relate to poor care transition.



Member       Debra Ness, National      Practice 25      Healthcare organizations should evaluate the effectiveness of transition protocols and policies, as well as evaluate transition outcomes. We concur that evaluation is key Comment supports draft report
             Partnership for Women and                  to improving health outcomes. Under additional specifications, we support the evaluation of adverse events, especially as they relate to poor care transition.
             Families


Non-member   Ellen Kurtzman, The George Practice 25     • The specifications fail to include evaluation of clinical outcomes. This is not consistent with NQF’s measurement priorities (e.g., measures of outcome).                No action taken. The practice statement clearly states the
             Washington University,                                                                                                                                                                                                transition outcomes should be evaluted
             Department of Nursing
             Education

Member       Gayle Fortner, HC21          Practice 25   Healthcare organizations should evaluate the effectiveness of transition protocols and policies, as well as evaluate transition outcomes. We concur that evaluation is key Comment supports draft report
                                                        to improving health outcomes. Under additional specifications, we support the evaluation of adverse events, especially as they relate to poor care transition.



Non-Member   Lauren Agoratus, Family      Practice 25    Preferred Practice #25 Healthcare organizations should evaluate the effectiveness of transition protocols and policies, as well as evaluate transition outcomes. We       Comment supports draft report, no action necessary
             Voices                                     concur that evaluation is key to improving health outcomes. Under additional specifications, we support the evaluation of adverse events, especially as they relate to
                                                        poor care transition.

Member       Mary Naylor, University of   Practice 25   • The specifications fail to include evaluation of clinical outcomes. This is not consistent with NQF’s measurement priorities (e.g., measures of outcome).                No action taken. The practice statement clearly states the
             Pennsylvania School of                                                                                                                                                                                                transition outcomes should be evaluted
             Nursing

Member       Sheree Chin Ledwell, Aetna Practice 25     Practice Statement #25 – The evaluation of the effectiveness of transition policies and procedures and transition outcomes could include patient satisfaction surveys or   Section on Opportunities for Measurement was edited to
                                                        other mechanisms to obtain member feedback.                                                                                                                                include pt satisfaction/experience with care measures




                                                                                                                    NQF DRAFT: DO NOT CITE, QUOTE, REPRODUCE, OR CIRCULATE                                                                                                                       18

				
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