Proportion of People Who Someone Followed-Up to Make Sure They Had Needed Services and Supports After Stay in a Hospital or Rehab/Nursing Facility

Identifying Attributes

Care Settings
Care Transitions
Country
United States of America
Publishing Organisation
Advancing States and the Human Services Research Institute (HSRI): National Core Indicators Survey - Aging and Disability
Type of Quality Indicator
Outcome
IOM Quality Dimension
Person-Centredness
Domain
Follow-Up

Defining Attributes

Definition

Proportion of people who someone followed-up to make sure they had needed services and supports after stay in a hospital or rehab/nursing facility (if had an overnight stay in the past 12 months and was discharged to go home) (Yes/No).

Numerator

Number of people who someone followed-up to make sure they had needed services and supports after stay in a hospital or rehab/nursing facility (if had an overnight stay in the past 12 months and was discharged to go home) (Yes/No).

Denominator

Number of people who had an overnight stay in the past 12 months and were discharged to go home (inferred).

Exclusions
Use of Risk Adjustment
No
Risk Adjustments

None

Stratifications

By state

Collection and Reporting Attributes

Type of Data Collection
Surveys
Data Collection Methods

Information for Adult Consumer Survey is collected via a direct conversation with the person receiving services either face-to-face, secure video conference, or over the phone. Survey is carried out to hear directly from people served by publicly funded long-term services and supports programs—known as LTSS. Additionally, background information is primarily collected from the individual's record. The main survey includes questions about personal experiences that may only be answered by the individual receiving services. Some questions are more observable about the individual's involvement in the community, their choices, respect and rights, and their access to services. These questions allow for the use of "proxy" or other respondents who know the individual well (such as a family member or friend). Each state is instructed to complete a minimum of 400 surveys with a random sample of older adults and adults with a physical disability who are receiving at least one publicly funded service beyond case management. Most states enter data into an online data entry system specifically designed for the purposes of this project (ODESA©).

Frequency of Data Collection
Annually
Frequency of Data Collection in Days
365
Reporting Methods

Reported on NCIAD website - Adult Consumer Survey National Report. National and individual state reports are available. nci-ad.org/reports/

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

Source and Reference Attributes

Technical Specifications

The National Core Indicators (NCI) provide information on beneficiaries' experience and self-reported outcomes of long-term services and supports for individuals with intellectual and/or developmental disabilities (I/DD) and their families. NCI includes an in person survey, family surveys for parents and guardians of adults and children who receive I/DD supports, and a staff stability survey. For the purpose of the Adult Core Set, only data from the NCI In-Person Survey will be reported. Therefore, the technical specifications for the NCI measure in the Adult Core Set include only the In-Person Survey.

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
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