Transitions of Care (TRC)

HEDIS Measure

Transitions of Care (TRC)

Line of business: Medicare

Data Collection Method:

Administrative (Claims)
Hybrid (HEDIS Chart Chase)

Medication Reconciliation Post-Discharge Only

Supplemental Data Submission

• Standard – Electronic Clinical Data System (ECDS) Layout
• Non-Standard - Medical Record

Measure Description

The percentage of discharges for members 18 years of age and older who had each of the following.

Four rates are reported:

Notification of Inpatient Admission. -- Documentation of receipt of notification of inpatient admission on the day of admission through 2 days after the admission (3 total days).

Receipt of Discharge Information. Documentation of receipt of discharge information on the day of discharge through 2 days after the discharge (3 total days).

Patient Engagement After Inpatient Discharge. Documentation of patient engagement (e.g., office visits, visits to the home, telehealth) provided within 30 days after discharge.

Medication Reconciliation Post- Discharge. Documentation of medication reconciliation on the date of discharge through 30 days after discharge (31 total days).

Numerator Compliance

Notification of Inpatient Admission – Administrative reporting is not available for this indicator. Documentation of receipt of notification of inpatient admission on the day of admission or on the day of admission through 2 days after the admission (3 total days).

Receipt of Discharge Information - Documentation of receipt of discharge information on the day of discharge through 2 days after the discharge (3 total days).
NOTE: Administrative reporting for Notification of Inpatient Admission and Receipt of Discharge Information is NOT available.

Patient Engagement After Inpatient Discharge – Patient engagement provided within 30 days after discharge.
Any of following meets compliance:
Outpatient, telephone, e-visit, virtual check-in or transitional care management services
NOTE: Patient engagement that occurs on the date of discharge is not compliant.

Medication Reconciliation Post-Discharge –. Medication reconciliation, which the discharge medications are reconciled with the most recent medication list in the outpatient medical record and conducted by a prescribing practitioner, clinical pharmacist, physician assistant or registered nurse on the date of discharge through 30 days after discharge (31 total days).

Best Practices

• Document in the member's medical record the date and time the PCP was notified of the member's in-patient hospital admission
• Date and time stamp the receipt of notification of admission
• Document in the member's medical record the date and time the PCP was notified of the member's in-patient hospital discharge
• Date and time stamp the receipt of the discharge summary in the member's medical record
• Obtain timely discharge summaries
• Reconcile the patient discharge medications to his or her outpatient medications
• Schedule appointments with primary care provider within the first seven days of discharge
• Remind patients of their appointment by making calls or sending texts
• Make outreach calls and/or send letters to advise members of the need for a visit

Quality Value Set Directory Coding Tips

Medication Reconciliation Encounter

Medication Reconciliation Intervention

Online Assessments

Outpatient

Telephone Visits

Transitional Care Management Services