Transfer of Health (TOH) Information to the Provider–Post-Acute Care (PAC)

Identifying Attributes

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

Defining Attributes

Definition

Percentage of inpatient rehabilitation facility (IRF) patient stays with an IRF-PAI discharge assessment indicating that a current reconciled medication list was provided to the subsequent provider at the time of discharge/transfer. Process-based measure that assesses whether or not a current reconciled medication list was provided to the subsequent provider when the patient was discharged or transferred from a Post-Acute Care setting to a subsequent provider.

Numerator

Number of IRF patient stays with an IRF-PAI discharge assessment indicating that a current reconciled medication list was provided to the subsequent provider at the time of discharge/transfer.

Denominator

The total number of IRF Medicare Part A and Medicare Advantage (Part C) patient stays ending in discharge to the following settings only: a short-term general hospital, a SNF, intermediate care, home under care of an organised home health service organisation or hospice, hospice in an institutional facility, a swing bed, another IRF, a LTCH, a Medicaid nursing facility, an inpatient psychiatric facility, or a critical access hospital.

Exclusions

Patients who died

Use of Risk Adjustment
No
Risk Adjustments

None

Stratifications

None

Collection and Reporting Attributes

Type of Data Collection
Standardised clinical data
Data Collection Methods

Data collected using Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) and submitted to the Centers for Medicare & Medicaid Services (CMS) via the Internet Quality Improvement and Evaluation System (iQIES).

Frequency of Data Collection
Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) is completed for each Medicare Part A fee-for-service and Medicare Part C patient discharged from an IRF. Data are submitted quarterly.
Frequency of Data Collection in Days
91
Reporting Methods

Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (CMS, and providers) Will be reported on CMS Care Compare - Inpatient rehabilitation facilities

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

Source and Reference Attributes

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)
No
Australian Consortium for Aged Care Endorsed
No
Identified by PHARMA-Care Project
No
Upload Date
02 December 2025