Transitions of Care - Average

Identifying Attributes

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

Defining Attributes

Definition

The average of the rates for Transitions of Care - Medication Reconciliation Post-Discharge, Transitions of Care - Notification of Inpatient Admission, Transitions of Care -Patient Engagement After Inpatient Discharge, and Transitions of Care - Receipt of Discharge Information.

Numerator
  1. Notification of inpatient admission: Documentation of receipt of notification of inpatient admission on the day of admission or the following day and 2. Receipt of discharge information: Documentation of receipt of discharge information on the day of discharge or the following day and 3. Patient engagement after inpatient discharge: Documentation of patient engagement (e.g., office visits, visits to the home, telehealth) provided within 30 days after discharge and 4. Medication reconciliation post-discharge: Documentation of medication reconciliation on the date of discharge through 30 days after discharge (31 total days).
Denominator

Acute or non-acute inpatient discharges for Medicare beneficiaries 18 years and older. The denominator is based on discharges, not members. Members may appear more than once.

Exclusions

Members in hospice; 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

Collection and Reporting 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

Average - measure not publicly reported

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 12 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
No
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
Can the Quality Indicator be Readily Implemented at a Population Level in Australia Given its Current Data Landscape?
Implementation of this quality indicator was not assessed.
Identified by PHARMA-Care Project
No
Upload Date
31 March 2026