Transitions of Care - Average
Identifying Attributes
Care Settings
Country
Publishing Organisation
Type of Quality Indicator
IOM Quality Dimension
Domain
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
- 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
Risk Adjustments
None
Stratifications
Collection and Reporting Attributes
Type of Data Collection
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
Frequency of Data Collection in Days
Reporting Methods
Average - measure not publicly reported
Reporting Frequency
Reporting Frequency in Days
Indicator Has Recommended Targets
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