Transfer of Health Information to the Patient Post-Acute Care

Identifying Attributes

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

Defining Attributes

Definition

The percentage of Skilled Nursing Facility resident stays with an MDS discharge assessment indicating that a current reconciled medication list was provided to the patient, family and/or caregiver at the time of discharge. A process-based measure that assesses whether or not a current reconciled medication list was provided to the patient, family, or caregiver when the patient was discharged from a Post-acute Care setting to a home setting.

Numerator

The number of SNF resident stays with an MDS discharge assessment indicating that a current reconciled medication list was provided to the patient, family and/or caregiver at the time of discharge.

Denominator

The total number of SNF Medicare Part A covered resident stays ending in discharge to the following settings only: a private home/ apartment (apt.), board/care, assisted living, group home, or transitional living.

Exclusions

Patients/residents who died or discharged home under the care of an organised home health service or hospice are not included in this measure.

Use of Risk Adjustment
No
Risk Adjustments

None

Stratifications

None

Data Attributes

Type of Data Collection
Standardised clinical data
Data Collection Methods

Collected using the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI).

Frequency of Data Collection
Data collection for this measure will begin on October 1, 2023. Data are collected on admission, on discharge (planned and unplanned), and for expired patients. Measures are updated monthly, at the facility and resident level, as data become available. MDS is transmitted to the CMS quarterly via the Internet Quality Improvement Evaluation System (iQIES).
Frequency of Data Collection in Days
30
Reporting Methods

Skilled Nursing Facilities Quality Reporting Program (CMS and Providers). Certification and Survey Provider Enhanced Reports (CASPER) Review and Correct Reports contain facility-level and resident-level measure information Will be reported on CMS Care Compare - delayed due to COVID-19.

Reporting Frequency
Quarterly
Reporting Frequency in Days
91
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
12 March 2025