The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
Bureau of Health Care Safety and Quality
99 Chauncy Street, 11th Floor, Boston, MA 02111
617-753-8000 

DEVAL L. PATRICK
GOVERNOR
TIMOTHY P. MURRAY
LIEUTENANT GOVERNOR
JUDYANN BIGBY, MD
SECRETARY
JOHN AUERBACH
COMMISSIONER	
Circular Letter: DHCQ 11-01-545

TO:	Hospital Chief Executive Officers 
Chief Medical Officers 
Chief Nursing Officers 
Quality Directors 
Case Management or Social Work Directors
	Long Term Care Facility Administrators and Directors of Nursing
	Home Health Agency Directors

FROM:	John Auerbach,
Commissioner

Alice Bonner, PhD, RN
		Director, Bureau of Health Care Safety and Quality

DATE:		January 18th, 2011

RE:		Care Transitions and Universal Transfer Form

We are writing this advisory memo with the following purposes in mind:

1) To summarize the status of important state and federal efforts to improve the quality of health care by insuring essential information is gathered and accompanies a patient transfer
2) To acknowledge the work that many of you have already undertaken to improve care transitions 
3) To encourage you to consider additional action steps and 
4) To ask for your feedback on certain materials and plans for the future.  With regard to this last point, we invite your participation in an upcoming conference call and an open comment period (details below).

Background on Massachusetts Efforts on Care Transitions:
Many of you provided input into the Massachusetts Statewide Strategic Plan for Care Transitions, which was unanimously approved by the Health Care Quality and Cost Council in February of 2010, and is posted on the HCQCC and Patient Care Link websites: http://www.patientcarelink.org/uploadDocs/1/Strategic-Plan-for-Care-Transitions_2-11-2010-(2).pdf.

The plan outlines 7 key principles. The Care Transitions Forum (CTF), a statewide community of interest, has been focusing on one principle, namely the feed back and feed forward of information during care transitions. While the key to improving information transfer lies in effective and integrated processes across settings, a standardized form for data transfer has been evaluated in numerous evidence-based national studies, and is considered an essential tool for improving care transitions. A workgroup of CTF members developed and designed a form (called the Universal Transfer Form or UTF) based on national models. With leadership from several professional organizations and government agencies, a number of health care systems have piloted and implemented the form. 

Overview of the Massachusetts and Federal Care Transition Forms:
The Department of Public Health would like to thank all the hospitals, post-acute care facilities, home health agencies, physician practices, consumers and others that have already contributed many hours to the UTF initiative.  The paper version of the Massachusetts UTF has been through two pilot phases and we have received valuable feedback from providers and other users across the continuum of care.  The pilot experiences have led to important revisions to the form; but more importantly they have generated new conversations in communities across the state on best practices around patient discharges and transfers that will ensure safe care. The interest and commitment from frontline staff, managers and leadership within health care organizations has been remarkable.

The UTF includes essential data elements developed from evidence-based studies and national consensus statements that are believed to be critical for safe and effective care transitions. During the course of the most recent pilot, we began discussions with hospitals and vendors around migration of the paper form into EHR. The exact order and formatting of the EHR versions will be modifiable, since individual organizations working with specific vendors and systems will have unique software capabilities and requirements. 

The federal government, as part of the “Meaningful Use Standards,” a document that is being issued by the Office of the National Coordinator (ONC), will also be providing guidance and information on developing systems for electronic data transfer among different healthcare settings.  The electronic tool that ONC will require for documenting a patient encounter and transferring that information to another provider is called the Continuing Care Document or CCD. The CCD does not mandate a format, but rather 18 essential data elements that must be included each time a patient is seen and an encounter documented. This information must go with the patient to the next set of providers (or be made available to them). 

In addition, the federal Centers for Medicare and Medicaid Services (CMS) is also working on a much longer transfer and assessment form called the CARE tool (Continuity Assessment Record and Evaluation), which is currently under development and being piloted by CMS in several states.  CMS will require all healthcare providers across settings to replace their current transfer forms with the CARE tool in all states in the future.  As a result, providers may want to consider adopting the Massachusetts UTF now in preparation for the CCD and/or CARE tool when each becomes required by the federal Government.

Details on the Massachusetts UTF:
The content and layout of the current UTF reflect important feedback we received from Massachusetts health leaders and frontline staff during the pilots. Physicians, nurses, social workers, physical therapists and others helped to determine the elements of the form, the formatting of various sections and the order of the data elements. As an example, when patients return to the emergency department (ED) from a post-acute setting (home, skilled nursing facility, rehabilitation facility, long term acute care hospital/LTAC), there is critical information that the ED staff need to have easily available on the first 1-2 pages of the UTF. Other sections of the form were reorganized so that documentation by individual disciplines (MD/RN/SW) was consolidated on specific pages to improve workflow, yet promoted interdisciplinary collaboration and accountability around important care issues.

A number of Massachusetts facilities have already replaced the older Patient Care Referral Form (known sometimes as the “Page 1, 2 and 3”) with the paper version of the UTF. In other cases, organizations have developed their own electronic version of the UTF and have made software changes that integrate the electronic form into their existing EHR. We encourage you to review the data elements and the specific wording of the elements on the Massachusetts UTF.  Since the goal of the UTF is to create a statewide standard with regard to care transitions, healthcare providers should work with their vendors and staff to determine the best approach to using the UTF data elements while they are also looking to implement the CCD requirements as well.

While the data elements themselves will be required, individual software vendors will work with their clients to determine the best format and means of integrating the UTF into existing workflow to optimize staff time, minimize or eliminate duplicative writing or copying of information, and promote the effective transfer of essential information. Ideally, we are moving toward a health information exchange (HIE) where data will be entered only once, and providers in any setting will be able to access that data from the HIE to care for an individual patient.

Institutions will also be expected to monitor their own compliance through quality assurance methods such as clinician chart reviews. For example, a clinician might be required to conduct a chart review of a sample of ten or more charts on an annual basis, to review the UTF for percent completion (all data elements/fields completed) and the percent of patients in the sample who had a UTF sent with them. State inspectors may request evidence of such chart reviews and performance improvement plans related to those activities on annual surveys or complaint investigations. 

We appreciate the innovative efforts of many individual institutions to refine and improve the UTF and to voluntarily adopt or work toward implementation of these enhancements over the coming months. However, we also recognize the urgent need for a statewide standard with regard to care transitions. Adverse events such as serious or fatal medication errors, missed follow up appointments, wound infections and avoidable rehospitalizations are occurring at an alarming rate, and are harming patients and affecting public health every day in the Commonwealth. While changes to state regulatory requirements have not been necessary to date, a regulatory approach is under consideration in the event that measurable improvements do not occur with the current strategy.

We anticipate further revisions to the paper and electronic versions of the UTF, based on feedback from Massachusetts communities as they implement the new forms and processes. We also plan on further communication specifically to home health agencies, outpatient practices and clinics, as those settings have unique issues related to electronic data transfer and the UTF that are not addressed in this letter. We are soliciting suggestions from organizations about the best way for “receivers” of patients to provide information back to “senders” (and the state) on what worked well and what needs improvement (if there are omissions in the data) in the care transition between specific institutions. Identifying ways to measure improvement will be critical to our state’s success.

We are inviting public comment over the next 60 days. If you or your EHR vendors wish to provide written comments or ask questions about the form or implementation, please contact Keith Chudyk at DPH at keith.chudyk@state.ma.us.  

We are also conducting an informational conference call on Monday, January 24th from 12:00 to 1:00 PM for any interested parties. Dial in number and pass code are below.

Dial in - 1-888-769-8918
Pass code - 6855820

Thank you once again for your efforts. We look forward to ongoing dialogue and collaboration as we all work to improve care transitions across settings in Massachusetts.