An Episode of Care definition includes all covered services across all providers that would typically treat a patient for a single illness or condition (hospital, physicians, laboratory, pharmacy, rehabilitation facility, etc.). HCI3‘s definitions are comprised of diagnosis, procedure and pharmacy code tables, which establish the episode’s triggers and boundaries.
These open source episode definitions can be used as the foundation for multiple purposes, including bundled payment and ACO payment programs, reference-pricing initiatives, and for cost and quality analysis of providers.
While HCI3‘s Episode of Care definitions are a core element of the PROMETHEUS Payment model, the definitions can be used for multiple initiatives and programs because of three distinct and important characteristics. These factors, found only in the our definitions, create a more complete and comprehensive episode:
Potentially Avoidable Complications
HCI3‘s Episode of Care definitions are the only definitions that distinguish typical and routine services from those associated with potentially avoidable complications (PACs). PACs were created to determine the amount of unexplainable variation in total costs of care that could be reasonably attributed to complications under the control of providers and can be used to create incentives for both cost-saving and for quality analysis.
There are two categories of PACs:
- Related to the index condition or stay – for example, an emergency department (ED) visit for keto-acidosis by a diabetic patient, or a repeat acute Myocardial Infarction (MI) within 30 days of discharge for a patient hospitalized with an AMI.
- Related to patient safety failures – for example, an adverse drug event for a patient with COPD, or a post-operative wound infection.
PACs have been defined as measures that count the frequency of complications. In January 2011, the National Quality Forum endorsed 4 PAC measures which cover acute myocardial infarction (heart attack), pneumonia, stroke and six chronic conditions: diabetes, congestive heart failure (CHF), hypertension, chronic obstructive pulmonary disease (COPD), asthma and coronary artery disease (CAD).
Potentially Avoidable Services
Our definitions flag, within specific episodes of care, the potentially avoidable services identified as overused services by the Choosing Wisely campaign. By doing so, they permit the ability to detect which physicians order which services on numerous occasions and whether those services are warranted.
HCI3‘s Episode of Care definitions incorporate core services for certain chronic conditions that are based on evidence-informed guidelines or expert opinion of recommended services for an identified time period. These core services can help identify gaps in care or underuse in the management of an episode and enables the tracking of expected versus observed progress.
For more information on the key features of HCI3‘s definitions, see the following resources*:
An Introduction to ECRs
HCI3 Learning Center Course 101: Episode of Care Basics
The History of the Development of the Prometheus Payment Model-Defined Potentially Avoidable Complications
Evidence-informed Case Rates: Paying for Safer, More Reliable Care
Reliability of Prometheus PAC Measures
HCI3’s Measures to Improve Quality and Outcome of Care for Patients Endorsed by NQF
*Some documents refer to a previous name for the Episode of Care definitions–ECRs–and will soon be updated; the substantive content remains valid