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The STAAR Initiative's work in Massachusetts, Michigan, and Washington is funded through a generous grant provided by The Commonwealth Fund.
 
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Measures

The STAAR Initiative’s measurement strategy integrates outcomes and process measures into a single cohesive approach.  It includes outcomes measures on 30-day all-cause readmissions rates; measures of patient experience from the Care Transitions Measure (CTM) and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey; and customized process measures for each of the initiative’s four key recommended changes.
 

 
1. Outcome Measures: Readmissions

 
 
30-Day All-Cause Readmissions (overall hospital and pilot-unit)
  • Percent of discharges with readmission for any cause within 30 days

 

30-Day All-Cause Readmissions (overall hospital and pilot-unit)

  • Percent of discharges with readmission for any cause within 30 days

 

Readmissions Count (overall hospital and pilot-unit)

  • Number of readmissions (numerator for 30-day all cause readmissions measure) for hospital and pilot unit(s)

 

Optional Measure: 30-Day All-Cause Readmissions for a specific clinical condition or subpopulation

  • Percent of discharges in the desired subpopulation who were readmitted for any cause within 30 days of discharge 
 
 
2. Outcome Measures: Patient Experience

 
 
HCAHPS Communication Questions (overall hospital)
  • “During this hospital stay, how often did nurses explain things in a way you could understand?” (Q3)
  • “How often did doctors explain things in a way you could understand?” (Q7)
 
HCAHPS Discharge Questions (overall hospital)
 
  • “Did hospital staff talk with you about whether you would have the help you needed when you left the hospital?” (Q19)
  • “Did you get information in writing about what symptoms or health problems to look out for after you left the hospital?” (Q20)
 
 
Care Transitions Measures (pilot unit)
 
  • The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital.
  • When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
  • When I left the hospital, I clearly understood the purpose for taking each of my medications.
 
 
 
3. Process Measures

 
 
Enhanced Admission Assessment for Post-Hospital Needs
 
  • Percent of admissions where patients and family caregivers are included in assessing post discharge needs
  • Percent of admissions where community providers (e.g., home care providers, primary care providers and nurses and staff in skilled nursing facilities) are included in assessing post discharge needs
 
Effective Teaching and Enhanced Learning
 
  • Percent of observations of nurses teaching patient or other identified learner where Teach Back is used to assess understanding
  • Percent of observations of doctors teaching patient or other identified learner where Teach Back is used to assess understanding
 
Real-time Patient- and Family- Centered Handoff Communication
 
  • Percent of patients discharged who receive a customized care plan written in patient-friendly language at the time of discharge
  • Percent of time critical information is transmitted at the time of discharge to the next site of care (e.g., home health, long term care facility, rehab care, physician office)
 
Post-Hospital Care Follow Up
 
  • Percent of patients discharged who had a follow-up visit scheduled before being discharged in accordance with their risk assessment
 
 
4. Balancing Measure

 
 
Observation admits
 
  • Number of admissions to observation status in the month