Transitions of Care - Patient Engagement After Inpatient Discharge

Identifying Attributes

Care Settings
Care Transitions
Country
United States of America
Publishing Organisation
National Committee for Quality Assurance: Healthcare Effectiveness Data and Information Set (HEDIS) measures
Type of Quality Indicator
Process
IOM Quality Dimension
Effectiveness
Domain
Follow-Up

Defining Attributes

Definition

Percentage of discharges for members 18 years of age and older who had documentation of patient engagement (e.g., office visits, visits to the home, telehealth) provided within 30 days after discharge.

Numerator

Number in the denominator with documentation of patient engagement (e.g., office visits, visits to the home, telehealth) provided within 30 days after discharge.

Denominator

Total number of acute or non-acute inpatient discharges for Medicare beneficiaries 18 years and older.

Exclusions

Members in hospice and members that do not have continuous enrolment from the date of discharge through 30 days after discharge (31 total days).

Use of Risk Adjustment
No
Risk Adjustments

None

Stratifications

Data Attributes

Type of Data Collection
Surveys
Data Collection Methods

HEDIS survey results directly from health plans and Preferred Provider Organisations (PPOs) through the Healthcare Organisation Questionnaire and non-survey data through the Interactive Data Submission System.

Frequency of Data Collection
Annually
Frequency of Data Collection in Days
365
Reporting Methods
Reporting Frequency
Annually
Reporting Frequency in Days
365
Indicator Has Recommended Targets
No

Source and Reference Attributes

Technical Specifications

Medicare 2023 Part C & Display Measure Technical Notes page 11 www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/PerformanceData

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