Transition Record With Specified Elements Received by Discharged Patients (Discharges From an Inpatient Facility to Home/Self Care or Any Other Site of Care)

Identifying Attributes

Care Settings
Care Transitions
Country
United States of America
Publishing Organisation
Centers for Medicare & Medicaid Services (CMS): Inpatient Psychiatric Facility Quality Reporting Program
Type of Quality Indicator
Process
IOM Quality Dimension
Effectiveness
Domain
Communication

Defining Attributes

Definition

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.

Numerator

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.

Denominator

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.

Exclusions

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

Use of Risk Adjustment
No
Risk Adjustments

None

Stratifications

Data Attributes

Type of Data Collection
Administrative data, Electronic/paper chart records
Data Collection Methods

Claims Data; Electronic Health Record/ Paper Medical Records.

Frequency of Data Collection
Annually
Frequency of Data Collection in Days
365
Reporting Methods

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

Reporting Frequency
Annually
Reporting Frequency in Days
365
Indicator Has Recommended Targets
No

Source and Reference Attributes

Evidence Source

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

Link to Measurement Tools
Quality Indicator Confirmed to be Part of a Program Used to Monitor Quality and Safety of Care Among Older People at a Population-Level between 2012-2022
Yes
Assessed by the Australian Consortium for Aged Care Collaborators as Generally Containing Good Properties (Importance and Scientific Acceptability)
Yes
Australian Consortium for Aged Care Endorsed
No
Identified by PHARMA-Care Project
No
Upload Date
12 March 2025