Issued ugust 4, 2016 Prepublication Requirements The Joint Commission has approved the following revisions for prepublication. While revised requirements are published in the semiannual updates to the print manuals (as well as in the online E-dition ), accredited organizations and paid subscribers can also view them in the monthly periodical The Joint Commission Perspectives. To begin your subscription, call 800-746-6578 or visit http://www.jcrinc.com. Post-cute Care Expansion Standards for the Integrated Care Certification PPLICBLE TO INTEGRTED CRE CERTIFICTION Effective January 1, 2017 Program lignment Chapter ICP.01.01.01 The program is organized to provide integrated care. Elements of Performance for ICP.01.01.01 1. The health care entities and clinical care sites that have organized into an integrated care program are identified in writing. 3. The program plans and organizes structures, processes, and resources to provide integrated care. 4. The program engages patients and families in order to guide the development and refinement of its structures, processes, and resources to support the delivery of integrated care. 5. The program evaluates available resources, identifies additional resources needed, and then obtains the needed resources to achieve the delivery of patient-centered, integrated care. Note: Resources include health care entities and clinical care sites. 6. The program s clinical care partners identify and agree on strategies, priorities, and timelines for achieving clinically integrated, patient-centered care, treatment, and services. ICP.01.01.03 Individuals responsible for program leadership are identified, and the roles and responsibilities of program leadership are defined. Elements of Performance for ICP.01.01.03 1. The program identifies individuals who are responsible for the integrated care program, including representatives from all participating clinical care partners. Copyright 2016 The Joint Commission 1
ugust 4, 2016 2. The program leaders delineate responsibility for planning and management of activities that are key to achieving and sustaining integration and coordination across clinical care partner sites. ICP.01.01.05 The program defines its mission, vision, and goals. Elements of Performance for ICP.01.01.05 1. The program describes in writing its mission, vision, and goals for clinical integration. 2. The mission, vision, and goals of the program guide the provision of comprehensive, patientcentered care, treatment, and services. 3. The program adopts a culture of safety that spans the continuum of care. 4. The program defines specific clinical and operational performance goals. ICP.01.01.07 The program s services and processes are designed to support the delivery of integrated care, treatment, and services that are population-based and patient-centered. Elements of Performance for ICP.01.01.07 1. The program s design of new or modified services or processes incorporates the needs of its patient population and clinical care partners. 2. The program identifies health care priorities for its patient population. 3. The program identifies health care disparities in its patient population. 4. The results of performance improvement activities influence the program s design of new or modified services or processes. 5. The program s design of new or modified services or processes considers potential risks to its patient population and incorporates mitigation strategies. 6. The program s design of new or modified services or processes incorporates evidence-based information in the decision-making process. 7. The program uses the identified health care priorities and health care disparities to inform the design of new or modified services. 8. The program tests and analyzes its design of new or modified services or processes to determine the impact on clinical care partners, patients, and families. Copyright 2016 The Joint Commission 2
ugust 4, 2016 ICP.01.01.09 Program communication processes facilitate the delivery of integrated care, treatment, and services that are safe, high-quality, and patient-centered. Elements of Performance for ICP.01.01.09 1. Program leaders provide for the resources needed to support timely communication of accurate patient health information among its clinical care partners. 3. The program requires and facilitates the use of clinical decision support tools to guide decision-making as applicable to its clinical care partners. 4. The program requires and facilitates the use of health information technology by clinical care partners in order to do the following: - Support the continuity of care - Document and track the care, treatment, and services the patient receives - Share the patient s goals for care, treatment, and services - Share data about the patient's health literacy needs - Share and synchronize the patient s plan for care - Support safe medication management - Support disease management - Support preventive care - Exchange information between clinical care sites - Support performance improvement activities 5. Program leaders monitor and evaluate the effectiveness of communication processes. Copyright 2016 The Joint Commission 3
ugust 4, 2016 Program Characteristics Chapter ICPC.01.01.01 The program s clinical care partners involve the patient and their family, when appropriate, in care and treatment planning and decisions. Elements of Performance for ICPC.01.01.01 1. The program s clinical care partners establish guidelines and performance expectations related to involvement of the patient and their family, when appropriate, in care, treatment, and services, whenever possible. These guidelines and performance expectations include at least the following: - Respecting patient rights to make decisions about his or her care and treatment - Identification of patient health literacy needs and provision of education that meets his or her needs - Encouraging patients to establish an ongoing relationship with a primary care clinician when they do not have one - Patient involvement in the development of his or her health, wellness, and treatment plans, including identified self-management goals - Establishing a patient/provider partnership to achieve planned health, wellness, and treatment goals and outcomes - Helping the patient learn about his or her responsibilities in the health care partnership, including providing accurate health history, following a medication regimen, and participating in self-management activities. - Patient education on self-management tools and techniques - Offering the patient information and education about advance care planning, based on the patient's expressed values, beliefs, and preferences for care ICPC.02.01.01 The program s clinical care partners provide care, treatment, and services in a manner that facilitates clinically integrated care. Elements of Performance for ICPC.02.01.01 1. The program incorporates the principles of chronic disease management models into the design and plan for providing clinically integrated care. 2. The program s clinical care partners use clinical practice guidelines to design or improve processes that evaluate and treat specific diagnoses, conditions, or symptoms. 3. The program requires clinical care partners use of an interdisciplinary approach in providing patient care, treatment, and services. 4. The program s clinical care partners identify the need for and composition of each patient s interdisciplinary team. The team must include a doctor of medicine or doctor of osteopathy. 5. The program s clinical care partners establish and fine-tune interdisciplinary team membership to provide comprehensive, coordinated care throughout the patient s course of care, treatment, and services. 6. The program requires and makes it possible for clinical care partners to form interdisciplinary teams that include representatives from different clinical care partner sites in order to meet a patient s needs. Copyright 2016 The Joint Commission 4
ugust 4, 2016 ICPC.03.01.01 The program facilitates transitions-of-care activities that promote patient safety and quality of care. Elements of Performance for ICPC.03.01.01 1. The program s clinical care partners define and implement risk-screening criteria for identifying patients in need of increased support to manage chronic, unstable illnesses. 2. The program s clinical care partners agree to manage transitions of care and provide or facilitate patient access to the following, as needed: - dmission to a hospital - Case management services or care coordination assistance - Primary care services - ppointments with clinical care partners following hospital admission - Preventive services that are age- and gender-specific - Behavioral health services - Oral health services - Substance use treatment services - Urgent or emergent care services - Home care services, including home health, home infusion, durable medical equipment, and hospice - Nursing care center services - Palliative care services - Rehabilitative services - Transportation for the purposes of care, treatment, and services Note: The services in this element of performance can be provided in person or by telehealth, when possible. 3. The program s clinical care partners establish a standardized communication process for care transitions that includes the following: - Standard method of information exchange - ctive collaboration when sending and receiving patients - Expectation that there is communication prior to patient transitions - Timelines for sending information - Defined clinical circumstances when communication between licensed independent practitioners is needed - Standardized method of documentation in the patient health record 4. The program s clinical care partners have access to patients plans for health, wellness, and treatment when needed to support their provision of care. Copyright 2016 The Joint Commission 5
ugust 4, 2016 5. The program s clinical care partners agree on defined time frames for sharing the following information, as relevant to patient care, treatment, and services: - Diagnostic tests performed and their results - Specific patient health information that is subject to privacy and confidentiality protections more restrictive than the Health Insurance Portability and ccountability ct (HIP) Privacy and Security Rules - Laboratory tests performed and their results - Procedures performed and their outcomes - Medications ordered, changed, or discontinued - Findings from history and physical data relevant to the patient s condition - Information on pending results of diagnostic tests, laboratory tests, and medical procedures - Immunization history - Rehabilitation progress notes - dvance care planning notes and documents (for example, advanced directives, living will, health care power of attorney) 6. The program s clinical care partners identify any conflicts regarding the care, treatment, and services planned for the patient and work collaboratively to resolve them. 7. The program describes its method for maintaining accountability for a patient s care, treatment, and services as he or she moves both among participating clinical care partners and between clinicians or health care entities outside the program. 8. The program has processes in place that mitigate the risk of duplicated or conflicted care coordination and case management services for patients. Copyright 2016 The Joint Commission 6
ugust 4, 2016 Quality, Safety, and Culture Chapter ICQS.01.01.01 The program establishes program-specific performance improvement priorities. Elements of Performance for ICQS.01.01.01 1. The program s leadership uses patient and family feedback to identify priorities for performance improvement. 2. The program s leadership sets priorities for performance improvement activities that include consideration of data related to close calls, near misses, hazardous conditions, and adverse safety events. 3. The program s performance improvement priorities and activities focus on patient outcomes. 4. The program s leadership reprioritizes performance improvement activities in response to changes across the continuum of care. For example, these changes could include infection control surveillance activities or variance in performance measurement results. ICQS.01.01.03 The program s leadership conducts performance improvement activities that span the continuum of care. Elements of Performance for ICQS.01.01.03 1. The ongoing performance improvement activities occur program wide. 2. Program performance improvement activities focus on improving the quality, safety, patientcenteredness, and clinical integration of care, treatment, and services. 3. The program collects data on chronic disease management outcomes. 4. The program collects data on patients experiences, including the following: - Patient access within established time frames - Patient experience and satisfaction with care, treatment, and services - Patient satisfaction with communication across the program, including education - Patient perception of comprehensiveness of care, treatment, and services - Patient perception of how well their care was coordinated across the program - Patient perception of the continuity of care, treatment, and services 5. The program collects and analyzes data on measures related to integration of care, in order to extract performance improvement opportunities. Examples of measures being collected by health care entities for other purposes that can contribute to understanding effectiveness of clinical care integration include the following: - Wait times for scheduling ambulatory care appointments - mbulatory appointment no-shows - Hospital readmissions - Hospital lengths of stay - Emergency department and urgent care utilization - Home care initial assessment visit timing, frequency of visits, referrals to the emergency department, and consistency in staff working with patients - Nursing care center patient transfers to the hospital, infection rates, and falls data Copyright 2016 The Joint Commission 7
ugust 4, 2016 6. The program uses collected and analyzed data to identify, plan, and implement improvements. ICQS.02.01.01 The program evaluates the effectiveness of its processes that support clinical integration and coordinated care. Elements of Performance for ICQS.02.01.01 1. The program evaluates how well it supports the continuity of care, including partnering with the patient to deliver care that meets the patient s needs. 2. The program evaluates new or modified services or processes to determine if expected results have been achieved. 3. The program evaluates the care, treatment, and services received by patients who are referred to nonprogram providers. Copyright 2016 The Joint Commission 8