Transitions of Care HEDIS measure focuses on medication management and care coordination

When a patient is transferred from one care setting (for example, a hospital, nursing facility, primary care provider, long-term care, home health care, specialist care) to another in an ineffective way, it can lead to confusion about treatment plans, missed follow-up appointments, patient dissatisfaction, medication nonadherence and, most importantly, unnecessary readmissions, according to the American Journal of Managed Care.

The Transitions of Care (TRC) HEDIS^® measure, which is also included in our series of Star Measure Tips, focuses on the percentage of members who had an acute or non-acute inpatient discharge during the measurement year and who had each of the following:

• Notification of inpatient admission
• Receipt of discharge information
• Patient engagement after inpatient discharge
• Medication reconciliation post-discharge

Documentation of all four components must be in any outpatient record, as well as accessible by the primary care doctor or ongoing care provider.

We encourage you to establish an office practice that explains to patients why it’s crucial that they inform your office about their hospital admissions and discharges. Let them know it’s important because it can improve their care coordination and help maintain their health and safety.

Read this tip sheet to learn more about the measure, including exclusions, best practices, and documentation requirements.

HEDIS^®, which stands for Healthcare Effectiveness Data Information Set, is a registered trademark of the National Committee for Quality Assurance, or NCQA.