Improving Health Outcomes During Transitions of Care

Patients, particularly the elderly and those with complex health needs, are at increased risk of complications and poor health outcomes when communication between care settings and providers is not well coordinated and documented. The NCQA/HEDIS Transitions of Care (TRC) measure is intended to improve patient outcomes by reducing or eliminating the incidence of medication errors, unnecessary or duplicate testing, increased emergency room visits, and readmissions to the hospital.

The measure assesses documentation of the transition of care for Medicare members 18 and older who have been discharged from an inpatient setting. According to NCQA specifications, Medicare beneficiaries 65 and older accounted for 11.9 million (or approximately 34 percent) of all hospital discharges in the United States in 2010. To improve outcomes for this at-risk population, the member’s primary care practitioner (PCP) should be notified of admissions and discharges in a timely and meaningful manner to ensure that the PCP can take action quickly.

Providers will meet the criteria for the TRC measure if their outpatient medical records include documentation in four main areas:

• Notice of the inpatient admission on the day of admission or the following day
• Receipt of the complete discharge summary on the day of discharge or the following day
• A completed medication reconciliation
• Patient/member engagement within 30 days of discharge. Engagement may be demonstrated by an office visit, a home visit, or telehealth visit. Patients in hospice are excluded from this measure.

You are advised to maximize your EMR system to capture any automated notices that may be generated from hospitals or other sources, such as Hixny. Please also educate your patients on the importance of scheduling and attending post-discharge follow-up visits.

For additional strategies for success with this HEDIS measure and others, refer to the 2019 HEDIS Tips Booklet for Providers found on the CDPHP provider portal under “Provider Resources” then “HEDIS Information.”