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New England Nursing Home
Quality Care Collaborative
(NE NHQCC)
A Guide to SERIES 1: Improving Transitions of Care
Contents
A Guide to SERIES 1: Improving Transitions of Care .......................................................................1
WELCOME! ..................................................................................................................................3
The Big Picture.............................................................................................................................4
Series 1: Improving Transitions of Care ............................................................................................. 4
11SOW AIMS: ..................................................................................................................................... 5
11SOW Goals: .................................................................................................................................... 5
Preparing Your Organization ........................................................................................................6
Quality Assurance Performance Improvment ................................................................................... 6
Make a commitment.......................................................................................................................... 6
Name it! ............................................................................................................................................. 6
Invest in training. ............................................................................................................................... 7
Organize learning circles. ................................................................................................................... 7
Have the right attitude....................................................................................................................... 7
Preparing Your Team ...................................................................................................................8
Build a team ....................................................................................................................................... 8
Tips for Team Building ....................................................................................................................... 8
Indicators of teamwork focus: ........................................................................................................... 9
Create a plan. ..................................................................................................................................... 9
The Training .............................................................................................................................. 10
The HATCh Model ...................................................................................................................... 11
Calendar of Events & Team Activities ......................................................................................... 13
March – December 2015 ................................................................................................................. 13
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WELCOME!
The New England Quality Innovation Network-Quality Improvement Organization is delighted to
have the opportunity to collaborate with you on this great educational journey! Throughout the
country, organizations are joining forces to improve the quality of care for residents. Together, we
are rallying around important topics that, through improvement efforts, can drastically change the
lives of residents and families. This collaborative provides greater safety and care and ensures that
residents do not experience harm on our watch.
You are part of something special. By committing yourself, your staff and your organization to this
process you are ensuring that better care will be achieved. We recognize that you are busy; and as
such, we have made every effort to create a program that will be easy for you to use and manage.
This guide will provide you with information to help map out the journey and provide insights into
successful strategies.
This material was prepared by the New England Quality Innovation Network-Quality Improvement Organization (QIN-QIO), the Medicare Quality Improvement
Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human
Services. The contents presented do not necessarily reflect CMS policy. 11SOWQIN-C2_042015_1189
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The Big Picture
Series 1: Improving Transitions of Care is the first of a five-part series that will happen over
the next five years. Improving transitions of care is our mission in Series 1. Transition of care refers
to the movement of patients between health care locations, providers, or different levels of care
within the same location as their conditions and care needs change. As a community, nursing home
staff refers to transitions as “discharge to hospital” or “admission from the hospital” but language
like that is limiting and keeps us from focusing on the big picture! The American Medical Directors
Association (AMDA) recommends the replacement of the concept of “discharge” from a health care
facility with that of “transition.” Discharge; by implying that “the patient is no longer our
responsibility” after he or she leaves the facility or the provider’s office, is an outmoded concept
that contributes to a lack of continuity of care. Transition, by contrast, extends medical providers’
responsibility for a patient into the “white space” between one setting of care and the next.
The language we use is only half the battle! The fact is that huge numbers of older, medically
compromised people who transition repeatedly are put in harm’s way. It increases their likelihood
of suffering an adverse event –usually related to medications, developing infections, increased
confusion for those with dementia and creates an incredibly costly burden on the healthcare
system to the tune of $17 billion.
Working on transitions of care will not only improve the lives of residents, help us better advance
quality systems within our organizations, but will also help to prevent unnecessary complications to
the lives of residents and staff alike. In other words, it’s the right thing to do!
On the following page, you will see the goals that the Centers for Medicare & Medicaid Services
(CMS) set forth for the Quality Innovation Network-Quality Improvement Organization (QIN-QIO)
Community. The learning series that we have created revolve around these CMS goals.
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CMS 11th Scope of Work (11SOW)
Quality Innovation Network (QIN) - Quality Improvement Organization (QIO)
August 1, 2014 - July 31, 2019
CMS AIMS:
AIM 1:
Healthy People,
Healthy Communities:
Improving the Health
Status of Communities
AIM 2:
Better Healthcare for
Communities:
Beneficiary-Centered,
Reliable, Accessible,
and Safe Care
AIM 3:
Better Care at
Lower Cost
CMS Goals:
Goal 1: Promote Effective Prevention and Treatment of Chronic Disease
•Improving Cardiac Health and Reducing Cardiac Healthcare Disparities
•Reducing Disparities in Diabetes Care: Everyone with Diabetes Counts (EDC)
•Using Immunization Information Systems to Improve Prevention Coordination
•Improving Prevention Coordination through Meaningful Use of HIT and Collaborating with
Regional Extension Centers
Goal 2: Make Care Safer by Reducing Harm Caused in the Delivery of Care
•Reducing Healthcare-Associated Infections in Hospitals
•Reducing Healthcare-Acquired Conditions in Nursing Homes
Goal 3: Promote Effective Communication and Coordination of Care
•Transitions of Care
Goal 4: Make Care More Affordable
•Quality Improvement through Physician Value-Based Modifier and the Physician Feedback
•Quality Reporting Programs
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Preparing Your Organization
We prepared this guide to ensure your success for the
Series 1 learning track, Improving Transitions of Care. It
will guide you and your staff through the initial process.
Quality Assurance Performance Improvment
Different than quality assurance which maintains the
quality of a certain process, procedure or project, Quality
Improvement Performance Improvement advances the
quality of a process, procedure or project -it moves
excellence forward! That is the aim of this project.
Ultimately, the quality improvement project that we are
about to undertake is to improve our processes of care to
keep residents safe. In doing that, we will look at systems
and processes within our organizations to determine their
effectiveness and advance changes that contribute to
great care. In essence, we are not doing one QI project but
many. The education has been built to support this work.
QAPI will be imbedded in the education process as we
go along.
Essentially, here is the work involved in this project.
a) Make a commitment.
Tips for Promoting a Culture
of Quality Improvement
 Educate staff about QI and
provide them with the skills to
participate in QI processes.
 Set a routine schedule for
monitoring and reviewing data.
 Communicate results from
improvement projects
throughout the clinic and the
community.
 Display data where patients can
see them.
 Celebrate successes.
 Articulate the values of QI in
meetings
 Provide opportunities for all
staff to participate in QI teams.
W. Edwards Deming, the father of the quality
movement, famously laid out 14 points for
 Reward staff members by
management—chief among them, the notion of
mentioning their QI
"constancy of purpose." Deming argued that a
contributions in their
company's commitment to quality had to come
performance evaluations.
from the top, and it had to be reinforced over and
over again. Unless an organization views quality as
its single, non-negotiable goal, workers will
inevitably feel the need to make tradeoffs and quality will slip.
b) Name it!
If you are going to commit to quality, first you must define exactly what quality is. View the
areas where improvement is needed in your transitions process as opportunities. From
where you are now, can you define where you want to be eight months from now? Go
ahead. Write the goals that you plan to accomplish through this program. Do you use
Interact; does staff need to better understand the link between CHF and residents going out
to the hospital. Look at the topics that we will be learning and determine where
improvements in the process, staff skills etc. can be advanced.
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c) Invest in training.
Quality experts recommend that organizations train workers at all levels to look for ways to
improve quality and to lessen problems. That is why we encourage you to use a model called
Pollination Education. It teaches small lessons to lots of people all throughout the
organization. The idea is to create buzz! Don’t feel you have to trumpet a new big project (a
sure way to kill it before it starts!). Just create buzz using the tools and materials we will be
sending. Think pollination. Sprinkle the learning here and there. Get social workers to teach
families; teach all staff and families about STOP & WATCH. See how creative you can be in
pollinating your organization with practices that help to reduce rehospitalizations.
d) Organize learning circles.
Organizing employees into learning circles can be an effective way to identify and address
problems. Simply put, learning circles are groups of employees who are encouraged to
discuss problems and recommend improvements, all with the goal of promoting quality,
efficiency, and great care.
To succeed, a learning circles should draw members from all corners of the organization. The
learning circles should be small in size seven or eight people; given a question on which to
deliberate; all members have two minutes of uniterrupted time to share their thoughts; you
can pass but are encouraged at the end of the session to offer comments. Once all have
spoken provide them with adequate resources to pursue their analysis, and schedule a time
in the future at which they may present their ideas. It is important that you act on their
recommendations.
e) Have the right attitude.
Too many people turn the quest to improve quality into something oppressive. Allow the
process to be fun, thoughtful and motivating.
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Preparing Your Team
Build a team
The concept of a team brings the full complement of “people power” to get the job done. Here are
some tips for chosing the team.
Tips for Team Building
A strong core improvement team is crucial to the success of your improvement efforts. Choose your
team members based on their knowledge, current involvement, and enthusiasm for the systems
and processes that you will work to improve. A good size team for a core improvement team is
seven members.
Have you noticed that some people get twice as much done in a day than do others? And they
always have time to take on one more tasks. Think about it. Is this a function of what they know?
More likely it is a function of their energy than of their skill level, number of degrees, or almost any
other characteristic or attribute. Energetic organizations are built on energetic people! Look for
sparkplugs!
Four elements of energy in people:
Stamina. The mind must be willing and the body capable.
The question is the level of staying power and the ability to
get that second wind when you need it.
Sense of Humor. Humor and laughter (not bawdy but funny
without any deprecation of anyone) is often critical to
sustain energy in oneself and in others. Humor is a leavener
and, where necessary, a leveler. At its best irony and whimsy
help us to see things that we would otherwise miss.
Optimism. Pessimistic people are energetic about their
complaints but once they make them (sometimes over and
over) they hit the wall. There is no other place to go. In
contrast optimistic people have few limits and their oftennaive faith drives change in a way that pessimism and even
realism cannot.
Enthusiasm. If optimism sees the future, enthusiasm is an
engine to get there. High voltage people (or high amperage if
you prefer) are charged for action. Enthusiasm is also
contagious and can spread energy simply by its forceful and
attractive presence.1
Give some thought to your
potetntial team members. Who
comes to mind as your read these
attributes? Go deep. Think of
other departments and positions.
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1
An article adapted from Innovating, the quarterly journal, for people in organizations and communities who lead
change by example. The Rensselaerville Institute, 63 Huyck Road, Rensselaerville, NY 12147
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Indicators of teamwork focus:
 An ability and desire to harness differences for better solutions vs. a desire to increase
harmony and cooperation.
 An interest in not simply coordinating but collaborating – creating something new that no
individual team member could achieve.
 Great teams build on divergent not similar views. Remember Mark Twain’s line: if five people
think alike, four of them are redundant.
Create a plan.
For the next eight months you will be engaging your staff in the process of change. Ultimately, you
will be working on the systems that improve your transitions process. You will want to constantly be
challenging people to think in new ways about transitions. You will certainly be learning new
techniques and skills.
All that said, what’s the plan? What can you put in place over the next month to ensure that the
next eight months will be truly productive and you will see the results you want? Take a look at the
following worksheet and shape your plan
Start Date
Task
Talk with Senior leadership about the process
Identify areas in which you will need their support and ask for it
Name a champion and alternate
Create a team
Include a family member and a resident
Review the online learning modules hosted on our website
Put all the call dates in your calendar
Share the call dates with the team
Set up training dates for each shift and department
Consider who else can help spread the message, teach and support the
work
Create buzz! You already have been transitioning residents back and forth
from various settings. How you are going to do it!
Post the team names
Share the work with your team and share ownership of the project
Meet with Family and Resident Council to discuss Transitions
Create a binder to store and manage all documents from the project
Check computers for sound and internet accessibility. Can staff use them
for our online education?
Determine the best way for your organization to receive materials
Complete the QAPI survey
Complete the survey monkey so that we can send you the materials
Completed
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The Training
We have worked with many people around the New England Region to bring you the best learning
modules possible. They are all designed to bring you the best and most current information and to
ensure that you can create change. We will be sending you materials, information, and resources so
don’t be concerned that you will need to create teaching materials. We have it covered! Be sure to
watch for them in your mail.
The program is set up with several different strategies for connecting:
a. There are regional webinars that bring all participants together to learn about the topic, get
updates and hear from other participants.
b. There are state webinars that bring local participants together to learn share, think through
barriers and cheer on successes.
c. There are learning modules that are available on-line. This is where you will find the
information to disseminate to staff.
d. There is an action period which gives you a chance to do the training and get staff working on
homework activities.
e. You will also receive periodic email communication that will supply other resources and
information.
Consider the best way to deliver these modules. As we mentioned previously there are several
strategies you can employ. Here are a few ideas:
 Download the training modules and teach and demonstrate them to designated people on the
team. Let them deliver them.
 Have staff complete the modules on-line. Gather staff into small groups to discuss all that they
have learned.
 Use stand-up and other gatherings to reinforce or teach the module.
 Use every opportunity to pollinate the ideas throughout the building.
 Get other departments to talk about these topics with their staff.
 Include staff on the calls that introduce the next learning module.
For more details about the learning module topics, activities, and webinar schedule, go to Page 13.
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The HATCh Model
To learn more, view the HATCh Model video
We introduce the HATCh
Model© to acquaint you
with a successful Quality
Improvement Tool used by
nursing homes across the
country to improve care.
A first step in reducing
rehospitalizations and
improving transitions is by
knowing the residents so
well that we can see subtle
changes in their energy,
health and cognition is
critical to the process. The
ultimate care for residents is
contingent upon the ability
to individualize their care.
The HATCh Model© was to designed to help organizations to individualize care. HATCh© stands for
the Holistic Approach to Transformational Change. It provides a picture of 6 important domains
which we found, through a national study supported by CMS (the Center for Medicare and
Medicaid Services) to be the key to making the necessary change from institutional to
individualized care.
Here’s a challenge for you. As you read the following description of the HATCh Model© consider
how it applies to transitions. Each domain plays a part in improving transitions. Read about the
following domains that make up the HATCh Model© and consider how these domains impact the
reduction of rehospitalizations. Read on.
You’ll notice the heart in the middle. It reflects a resident. All the work related to the HATCh
Model© always puts the resident first. HATCh© considers six inter-related domains that lead to
personal, organizational, community, and systems changes, all of which are necessary for a
transformation from institutional to individual care to take place. The three circles that most closely
affect the individual are within the 3 domains of Workplace Practice, Care Practices and
Environment.
Workplace Practice refers to all of the activity, procedures and individuals whose labor and efforts
impact residents. This domain is critical because of the correlation between good jobs and good
care. Very specific procedures are put in place to strengthen and support workers within this
domain-education, social supports, knowing each worker individually; responding to their concerns,
orientation and hiring practices and highly responsive human resource practice are all part of this
domain.
Care practices include the entire host of ways that people are cared for within a home. In the
HATCh Model we see a critical piece of this domain as all of the medical care given, attention to
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clinical care and systems, the arena of quality improvement along with the activities, rituals,
celebrations, and the dying, waking, and dining process just to name a few considerations. It is
important to note that in the HATCh model, Care Practices are not limited to residents, but includes
the staff and families as well.
The environment describes the surroundings in which an individual finds themselves. The ultimate
achievement for an organization within this domain is to create the environment that most reflects
the resident and the resident’s goals. If it is their hope to return home after completing rehab, than
their room might be homey but not have many permanent personal items. For the person who will
be staying long term, a homier and nurturing accommodation might be in order. There must be an
honoring of the human need for connection, for privacy, to be able to make decisions, to have the
space reflect their own individuality, and to create ways for individuals to bond with their own
space. This then is the requirement if we are serious about helping to create home in our nursing
homes.
The environment addresses the type of culture and values of the organization as well. Is it an
organization renown historically for its great care, notable caring staff, a place of peace and trust or
is it a busy work site where people remain distant from residents, carry on their private
conversations and gossip. The climate or environment experienced is the one in which a resident
might spend the rest of their lives.
Leadership is the fourth domain but is the place we often start our work. Notice how the three
domains sit in the midst of leadership. Here, the goal is to transform the role and nature of
leadership to a shared and empowered position. Helping everyone develop their personal
leadership skills ensures that the voices of everyone are heard and acted upon. This includes
nursing assistants, housekeepers, and dietary aides, as well as all the usual leaders. Leadership
practices should model the way, inspire a shared vision, challenge the process, enable others to act,
and encourage the heart (based on the work of Kouzes and Posner). A visible leader is one who
enters into relationships with staff and families alike, and creates an environment where honest,
open relationships and communication can serve all parties.
The domain of Family and Community encircles each nursing home creating inclusion and
opportunities for all to become involved. Families are on many of the committees and work groups
that affect the residents and home. They play an integral role and help to serve as a barometer. The
successful organization has porous access with the community- a natural flow between the
neighborhood and community, each utilizing and accessing each other as collaborative partners. No
longer is the nursing home isolated but instead an integrated part of the community.
The Regulatory/Government/Stakeholders domain ensures that those with the influence and power
to sustain the change share this work in transformation. The process is one of education and
awakening ensuring that policies and regulations are in harmony with the ability for residents to live
out their highest practicable physical, mental and psychosocial well-being. Through the work of
change organizations bring regulators into the process to collaborate and ensure success.
HATCh© serves as a means by which we can improve transitions. We’ll talk more about it over the
course of the following lessons but it will serve as foundation for this work.
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Calendar of Events & Team Activities
March – December 2015
 Participate in the Collaborative Kick-Off Webinar on 3/26.
 Review the slides and next steps from the webinar.
 Identify a team champion and an alternate champion
 Identify the team
 Conduct a technology check
 Make a plan to roll out the educational program
 Release of Pre-Work Module: QAPI
o Complete the QAPI Assessment
 Release of Module: Introduction to Transitions
 Champion and team reviews Module and determine the best way
to use the information as an education tool for staff
(and residents)
 Educate the staff (and residents)
 Release of Module: Preventing Adverse Events
 Champion and team reviews Modules and determines the best
way to use the information as education tools for staff
(and residents)
 Educate the staff (and residents)
 Participate in your State Webinar/Sharing Forum on 5/14.
 Track your progress; Review your data; Discuss your PIP process
with the team
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March – December 2015
 Release of Module: Reducing Healthcare-Acquired Infections
 Release of Module: Advance Directives
 Champion and team reviews Modules 4 and 5 and determines the
best way to use the information as education tools for staff
(and residents)
 Educate the staff (and residents)
 Ask questions and stay in touch with your QIN-QIO State Lead
about your team’s progress.
 Participate in the Regional Webinar on 7/9.
 Release of Module: End-Of-Life Care
 Champion and team reviews Module 6 and determines the best
way to use the information as education tools for staff
(and residents)
 Educate the staff (and residents)
 Track your progress; Review your data; Discuss your PIP process
with the team
 Champion and team reviews Module and determines the best way
to use the information as education tools for staff
(and residents)
 Educate the staff (and residents)
 Ask questions and stay in touch with your QIN-QIO State Lead
about your team’s progress.
 Participate in your State Webinar/Sharing Forum on 9/10.
 Release of Module: Improving Areas of Clinical Risk
 Release of Module: Getting a Seat at the Referral Table
 Champion and team reviews Module 8 and determines the best
way to use the information as education tools for staff
(and residents)
 Educate the staff (and residents)
 Ask questions and stay in touch with your QIN-QIO State Lead
about your team’s progress.
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March – December 2015
 Release of Module: INTERACT Training
 Champion and team reviews module and determines the best way
to use the information as education tools for staff
(and residents)
 Educate the staff (and residents)
 Submit progress tracking to your QIN-QIO State Lead
 Attend an in-person session in Concord, New Hampshire on 10/29,
CEUs pending.
 Release of Module: Discharge to Community
 Champion and team reviews Module 9 and determines the best
way to use the information as education tools for staff
(and residents)
 Educate the staff (and residents)
 Submit progress tracking to your QIN-QIO State Lead
 Attend in-person session in Worcester, Massachusetts on 12/3,
CEU pending.
 Prepare for Series 2: Reducing Antipsychotic Drug Use
(Dec 2015 – Aug 2016)
 Participate in Series 2 Webinar/Sharing Forum on 12/17.
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