Percentage of patients discharged from an inpatient facility to home or any other site of care, or their caregiver(s), who received a transition record (and with whom a review of all included information was documented) at the time of discharge including, at a minimum, all of the specified elements.

Number of patients or their caregiver(s) who received a transition record (and with whom a review of all included information was documented) at the time of discharge including all of the following: 1. Inpatient Care: Reason for inpatient admission, AND Major procedures and tests performed during inpatient stay and summary of results, AND Principal diagnosis at discharge 2. Post-Discharge/ Patient Self-Management: Current medication list, AND Studies pending at discharge (e.g., laboratory, radiological), AND Patient instructions 3. Advance Care Plan: Advance directives or surrogate decision maker documented OR Documented reason for not providing advance care plan 4. Contact Information/Plan for Follow-up Care: 24-hour/7-day contact information including physician for emergencies related to inpatient stay, AND Contact information for obtaining results of studies pending at discharge, AND Plan for follow-up care, AND Primary physician, other health care professional, or site designated for follow-up care.

Total number of patients, regardless of age, discharged from an inpatient facility (e.g., hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home/self care or any other site of care.

Patients who died, patients who left against medical advice or discontinued care.

None

Claims Data; Electronic Health Record/ Paper Medical Records.

Inpatient Psychiatric Facility Quality Reporting Program (CMS and Providers) CMS Care Compare - Hospitals and Provider Compare (Publicly reported).

Benjenk I, Shields M, Chen J. Measures of Care Coordination at Inpatient Psychiatric Facilities and the Medicare 30-Day All-Cause Readmission Rate. Psychiatr Serv. 2020 Oct 1;71(10):1031-1038. doi: 10.1176/appi.ps.201900360. Epub 2020 Aug 25. PMID: 32838680; PMCID: PMC7837251. National Quality Forum: Emergency Department Transitions of Care: A Quality Measurement Framework ciesandiego.org/wp-content/uploads/2018/07/National-Quality-Forum-Emergency-Department-Transitions-of-Care.pdf data.cms.gov/provider-data/topics/hospitals/psychiatric-unit-services data.cms.gov/provider-data/topics/hospitals/measures-and-current-data-collection-periods Reported on data.cms.gov/provider-data/dataset/dc76-gh7x

cmit.cms.gov/cmit/#/MeasureView/?variantId=1811&sectionNumber=1