The percentage of discharges from inpatient facilities for Medicaid MLTSS participants age 18 and older for whom a long-term services and supports care plan update occurred within 30 days of discharge. Long-term Services And Supports Reassessment/Care Plan Update After Inpatient Discharge (MLTSS-4) 2.

Reassessment and Care Plan Update after Inpatient Discharge Long-term services and supports reassessment and care plan update on the date of discharge or within 30 days after discharge. Reassessment must document evidence of the nine core elements described above and the reassessment date. The care plan update must be conducted during a face-to-face encounter between the care manager and the participant unless there is documentation that the participant refused a face-to-face encounter. A care plan developed in the inpatient facility on the day of discharge meets the requirement. Care plan update must document evidence of the nine core elements described below and the care plan date. Documentation of "no change" does not meet numerator criteria.

A systematic sample of inpatient discharges from the eligible population The denominator is based on discharges, not on participants. Participants may appear more than once in the sample.

1. Discharges for Planned Admissions Exclude planned hospital admissions from the measure denominator. A hospital stay is considered planned if it meets any of the following criteria. * Hospital stays with a principal diagnosis of pregnancy or a condition originating in the perinatal period (MLTSS-4 Value Sets Perinatal Conditions Diagnosis Codes) * Principal diagnosis of maintenance chemotherapy (MLTSS-4 Value Sets Chemotherapy Encounter Diagnosis Codes) * Principal diagnosis of rehabilitation (MLTSS-4 Value Sets Rehabilitation Diagnosis Codes) * Organ transplant (MLTSS-4 Value Sets Kidney Transplant Procedure Codes, Bone Marrow Transplant Procedure Codes, Organ Transplant Other Than Kidney Procedure Codes, Introduction of Autologous Pancreatic Cells Procedure Codes) * Potentially planned procedure (MLTSS-4 Value Sets Potentially Planned Procedures Procedure Codes) without a principal acute diagnosis (Acute Condition Diagnosis Codes) The exclusion for planned admissions is not reported with the measure performance rates. 2. Participant Could Not Be Contacted Participants who could not be contacted for assessment and care planning update following inpatient discharge. At least three attempts were made to contact the participant, including the date and mode of each contact (e.g., phone call, letter, email), but the participant could not be reached. To calculate the rate of participants who could not be reached divide the number of participants meeting this exclusion criterion by the number of participants meeting the continuous enrolment criteria. 3. Participant Refused Assessment or Care Planning Participants who refused to participate in an assessment or development of a long-term services and supports comprehensive care plan following inpatient discharge. To calculate the rate of participants who refused, divide the number of participants who meet this exclusion criterion by the number of participants meeting the continuous enrolment criteria.

None

Paper Medical Records.

Medicaid Managed Long-Term Services and Supports reporting to CMS Not reported on CMS Care Compare or Provider Data Catalogue.

www.medicaid.gov/medicaid/home-community-based-services/home-community-based-services-quality/long-term-services-supports-quality-measures/index.html

cmit.cms.gov/cmit/#/MeasureView?variantId=2524&sectionNumber=1 www.medicaid.gov/sites/default/files/2023-01/mltss-tech-specs-res-manual-2022-updated.pdf