Improving Safety of Transitions to Skilled Nursing Care Using Videoconferencing

ECHO-Care Transitions is a healthcare outreach program utilizing videoconferencing technology
to improve the quality and efficiency of care transitions for medically-complex elderly
patients by connecting post-acute care facilities that receive BIDMC patients with a
multidisciplinary BIDMC team that sends these patients following discharge. This case-control
study seeks to determine if ECHO-CT can improve clinical outcomes and reduce cost and
resource utilization during transitions of care in both an academic (BIDMC Boston) and
community (BIDMC Needham) hospital.

Our prospective cohort study of the ECHO-CT intervention will take place in the two
Boston-area hospitals, one providing tertiary care and one community-based care, in which the
outcomes of patients transferred to Skilled Nursing Facilities (SNFs) associated with these
hospitals will be compared to those transferred to SNFs from similar hospitals in New
England. We will also be comparing outcomes from individual patients enrolled in the ECHO
program to matched controls. Using a national database available from the Brown University
Center for Gerontology and Healthcare Research, the outcomes of Medicare beneficiaries
residing in SNFs that are participating in ECHO-CT will be compared to those in the
comparison group using a difference-of-difference analytic approach. Analyses will be
adjusted for potential confounders as appropriate.

In this study, the investigators also plan to measure satisfaction as well as process,
utilization, cost and patient safety outcomes to determine best practices for implementing
the program at a community hospital and affiliated SNFs.

Data will be obtained from the following sources:

1. Protected health information (PHI) from resident assessment data, as well as Medicare
claims and enrollment data to be obtained via a data use agreement (DUA) with the
Centers for Medicare and Medicaid Services (CMS) by the Brown University Center for
Gerontology and Health Care Research during years 2-3 of the study to include the
following:

1. The resident Minimum Data Set Resident Assessment (MDS) assessments. The MDS has
nearly 400 data elements including cognitive function, communication/hearing
problems, physical functioning, continence, psycho-social well-being, mood state,
activity and recreation, diagnoses, health conditions, nutritional status,
oral/dental status, skin conditions, special treatments, and medication use. The
assessments are done for all patients admitted to Medicare and Medicaid certified
SNFs, including enrollees in both traditional Medicare and Medicare Advantage.
These data will already be housed at Brown University,Brown has an active DUA to
obtain quarterly pulls of the population of MDS assessments .

2. Medicare claims which will be used to ascertain 30-day costs, re-hospitalizations,
and use of other medical services by Medicare fee for service (FFS) patients
admitted to the SNFs. The data also include diagnosis fields to ascertain
comorbidities.

3. Medicare enrollment file includes demographic information such as sex and race,
dates of birth and death, and various indicators of Medicare/Medicaid eligibility,
Part D eligibility, and Medicare Advantage enrollment.

4. BIDMC will collect and share ECHO-CT participating patient's social security number
and health insurance claims number with Brown University. Their clinical
information will be matched with control patients from the Medicare claims data to
show study effect on 30-day costs, re-hospitalizations rate and patient length of
stay.

2. In addition to aggregates derived from above, facility level data will come from the
Certification and Survey Provider Enhanced Reporting (CASPER) data, which are publicly
available and based upon facility surveys for Medicare/Medicaid certification. They will
be used in addition to data from "Nursing Home Compare and the Long Term Care: Facts on
Care in the US (LTCFocus.org) websites to describe the SNFs.

3. Intervention-specific data: Project-specific quality improvement data derived from
questionnaires, staff satisfaction surveys, and structured meeting minutes will be
designed and evaluated by BIDMC and Hebrew Senior Life

1. SNF Satisfaction: Every 6 months the investigators will send a satisfaction
questionnaire to the hospitals and SNFs participating in ECHO-CT to assess their
views of the ECHO-CT sessions, the value of time spent, feelings of empowerment,
inter-professional relationships, learning, and recommendations. All answers to the
survey questions will be kept strictly confidential. This information will be used
to improve the content and organization of the sessions and to develop tools for
dissemination (Aim 3). The investigators will develop the satisfaction
questionnaire during the first 6 months of the project, building upon our previous
survey experience and literature review. Metrics to quantify the quality of
transitional care will be derived from the work of Coleman et al.3 and incorporated
into the questionnaire. Survey design and evaluation will be conducted by the
outcome evaluation group under the leadership of Dr. Thomas Travison at Hebrew
SeniorLife's Institute for Aging Research.

2. Process assessment: The investigators will keep attendance logs to assess adherence
to the ECHO-CT intervention and its changes over time. Any consistent decline in
staff attendance for 2 or more weeks will be followed up by phone calls to assess
barriers to participation and corrective actions will be taken. These may include
changing to a more convenient time, identifying other providers who can attend
instead, contacting facility administrators or medical directors for their support,
and providing incentive gifts or continuing education credits In addition, during
each ECHO-CT session, the hospital based team will inquire about unexpected
outcomes or issues that arose during the transition process, including those
related to patients already discussed. This element will allow for an ongoing
technology-enabled learning platform and continuous quality improvement mechanism
over the course of the proposed project. The value of the video-conferencing
approach is that it creates a mutually trusting learning community in which "all
teach and all learn."

Facility Inclusion Criteria:

- SNF receives approximately the middle third of referral volume (approx. 20-100
referrals/ average 40 per year)

- SNF not so highly engaged with acute hospital that their patients are less likely to
benefit from the intervention.

- SNF affiliated with BIDMC Boston or BIDMC Needham

Facility Exclusion Criteria:

- Has not recently participated in ECHO CT

- Do not send anyone to ECHO CT training

- Clinicians are unwilling to make a commitment to attend at least 75% of video
conferences

Patient Selection:

ECHO-CT Group:

Inclusion Criteria: Patients that were discharged from BIDMC and admitted to skilled
nursing facilities that are participating in ECHO-CT between April 2019 and March 2021.

Exclusion Criteria: Patients discharged from a hospital other than BIDMC. Patients admitted
to a skilled nursing facility that is not participating in ECHO-CT.

Control Group:

Inclusion Criteria: Patients from skilled nursing facilities not participating in ECHO.

Exclusion Criteria: Patients discharged from BIDMC to one of our participating SNFs during
the study period of April 2019- March 2021