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
Country
Publishing Organisation
Type of Quality Indicator
IOM Quality Dimension
Domain
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
Risk Adjustments
None
Stratifications
Data Attributes
Type of Data Collection
Data Collection Methods
Claims Data; Electronic Health Record/ Paper Medical Records.
Frequency of Data Collection
Frequency of Data Collection in Days
Reporting Methods
Inpatient Psychiatric Facility Quality Reporting Program (CMS and Providers) CMS Care Compare - Hospitals and Provider Compare (Publicly reported).
Reporting Frequency
Reporting Frequency in Days
Indicator Has Recommended Targets
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