The number of all-cause hospitalisations within 30 days of discharge from another hospitalisation per 1,000 eligible beneficiaries from the specified geographic area.

Number of all-cause hospital readmissions to an acute care hospital within 30 days of acute care hospital discharge.

The total people-time count of hospitalisation at-risk fee-for-service (FFS) beneficiaries living within the target community, with beneficiary residence identified via the CMS Denominator file, standardised to the number of days in the measure window. People-time tabulation for each beneficiary considered date of eligibility and date of death, as well as monthly enrolment status (FFS or Medicare Advantage).

Same-day hospital transfers as well as readmissions to critical access hospitals (CAHs) and any hospital other than a conventional prospective payment hospital (psychiatric, rehabilitation, long-term acute, and other special hospitals) are excluded. This measure also excluded rehospitalisations when a beneficiary's ZIP Code at the subsequent hospitalisation no longer coincided with the target area.

Claims based

Based on eight quarters of data

Brock J, Mitchell J, Irby K, Stevens B, Archibald T, Goroski A, Lynn J; Care Transitions Project Team. Association between quality improvement for care transitions in communities and rehospitalizations among Medicare beneficiaries. JAMA. 2013 Jan 23;309(4):381-91. doi: 10.1001/jama.2012.216607. PMID: 23340640.

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