Get Rewarded for Improving Health Outcomes: Transitions of Care Program

Our  Transitions of Care (TOC) program helps members with complex care issues better manage their health after a hospital admission. Our team educates them about their condition; shares needed resources and works with them to find the right care to feel better.

Care Management program information is available to our members on the Live Well section of our member website.

To help improve health outcomes, the Transitions of Care Healthcare Effectiveness Data and Information Set (HEDIS®) measure is included in our Quality Incentive Program (QIP). You can earn incentives and help your patient have a successful transition from hospital to home.

This measure requires one follow-up visit within 30 days of discharge, and for medications prescribed at discharge to be reconciled with outpatient medications in the patient medical record within 30 days of discharge.

Please visit Quality Improvement to learn more about the QIP program from our brochures that provide detailed measure and coding information and helpful tips to ensure you receive credit for providing these services.

HEDIS Tips for Transitional Care visit (TRC)

This measure includes the percentage of patients that received continuity of care following an inpatient discharge, that are 18 years of age or older, who had each of the four components shared below, and completed and documented in the outpatient medical record. The components include Notification of Inpatient Admission, Receipt of Discharge Information, Patient Engagement After Discharge, and Medication Reconciliation Post Discharge.

Notification of Inpatient Admission

Documentation in the outpatient medical records must include evidence of receipt of notification of the inpatient admission with evidence of the date when the documentation was received. It should also be integrated into the appropriate medical record and made available to the primary care provider (PCP) or ongoing provider. Notification and integration must occur on the day of the discharge, through two days after discharge (three days total).

Examples that meet the criteria:

• Communication between inpatient providers, hospital staff, emergency department, and the member’s PCP or ongoing care provider regarding admission (like a phone call, email, or fax).
• Communication about the admission through a health information exchange, an automated admission, discharge and transfer alert system, or a shared electronic medical record (EMR).
• Documentation that the member’s PCP or specialist admitted the member to the hospital.
• Communication about the admission from the members health plan.
• Documentation that the PCP or specialist placed orders for test and treatments anytime during the inpatient stay.
• Documentation of a preadmission exam or planned admission prior to the admission date. The medical record must refer to the planned admission, not documenting just presurgical or pre-op. The time frame for the planned admission is not limited to the day of admission through two days after the admission.
• When an emergency room visit results in inpatient admission.
• Evidence that the PCP or specialist communicated with the emergency room about the admission.

Receipt of Discharge Information

Documentation in the medical record must include receipt of a discharge, and evidence the information was integrated in the medical record on the day of the discharge through two days after discharge (three days total).

Discharge information can include a discharge summary or summary of care record or be in structured fields in an EMR. It must include the date of receipt and all the following information:

• The practitioner responsible for the patient’s care during the inpatient stay.
• Procedures or treatments provided.
• Diagnosis at discharge.
• Current medication list.
• Testing results, documentation of pending tests or documentation of no tests pending.
• Instructions for patient discharge.