The purpose of this project is to:

• quantify the complexity of the coordination of patient care in rural health care systems; and
• expand our work on developing quality measures for rural patients whose care is transferred between providers.

This project will involve analysis of Medicare Current Beneficiary Survey (MCBS) and primary data collected through provider interviews and input from a Technical Expert Panel. The MCBS data will be used to identify the characteristics of the rural Medicare patient population, providers, and care pathways most at risk for communication challenges resulting from transfers. We will conduct 25 to 30 interviews with rural and urban health providers who regularly send/accept patient transfers from/to rural areas to identify the most important quality-related communication issues related to patient transfers. These results will help us to refine our existing set of transfer measures. We also will consider the use of the existing measures on a broader set of transfer conditions (beyond surgery, trauma, pneumonia and chest pain patients) as used in the field test and will develop a set of revised quality measures that assess the adequacy of inter-provider communication. Aspects of communication to be addressed include the completeness and timeliness of communications. We also will examine the feasibility of developing measures related to the timeliness and outcomes of transfers.

Publications

• Care Transitions: "Time to Come Home"
  Policy Brief
  Upper Midwest Rural Health Research Center
  Date: 03/2011
  This policy brief examines care coordination, with a focus on the transitions from inpatient care back to the rural community, and suggests ways of measuring the quality of care coordination on discharge from the hospital.
• Care Transitions: "Time to Come Home" (Full Report)
  Upper Midwest Rural Health Research Center
  Date: 03/2011
  This report looks at care coordination for rural patients, with a focus on transitions from inpatient care back to the rural community, and suggests ways of measuring the quality of care coordination on discharge from the hospital.