Transitions of Care HEDIS Measure: Medication Management and Care Coordination

According to the American Journal of Managed Care, the ineffective transferring of a patient from one care setting (e.g., a hospital, nursing facility, primary care physician (PCP), long-term care, home health care, specialist care) to another often leads to confusion about treatment plans. This can cause missed follow-up appointments, patient dissatisfaction, medication nonadherence and, most importantly, unnecessary readmissions.

The Transitions of Care (TRC) HEDIS measure for star ratings 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 an outpatient record that is accessible to the PCP or ongoing care provider.

We encourage you to establish an office practice that helps patients understand why it’s critical they inform your office about their hospital admissions and discharges. Let them know this is important because it can improve their care coordination and maintain their safety.

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

Healthcare Effectiveness Data Information Set. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).