Transitions of Care (TRC)

Assesses key points of transition for Medicare beneficiaries 18 years of age and older after discharge from an inpatient facility. Four rates are reported:

1. Notification of Inpatient Admission. Documentation in the medical record of receipt of notification of inpatient admission.
2. Receipt of Discharge Information. Documentation in the medical record of receipt of discharge information.
3. Patient Engagement After Inpatient Discharge. Evidence of patient engagement (e.g., office visits, visits to the home, telehealth) provided within 30 days after discharge.
4. Medication Reconciliation Post-Discharge. Medication reconciliation on the date of discharge through 30 days after discharge.

Why It Matters

Transition from the inpatient (hospital) setting back to home often results in poor care coordination, including communication lapses between inpatient and outpatient (a setting other than a hospital) providers; intentional and unintentional medication changes; incomplete diagnostic work-ups; and inadequate patient, caregiver and provider understanding of diagnoses, medication and follow-up needs.¹

One study estimated that inadequate care coordination and poor care transitions resulted in $25–$45 billion in unnecessary spending in 2011.² With hospital stays costing the U.S. $377.5 billion per year and increased lengths of stay for Medicare beneficiaries, there is pressure for hospitals, health plans and providers to improve delivery and coordination of care and lower risks for these patients. This includes examining the admission and discharge processes to prevent rehospitalization, ED visits and other poor health outcomes.³

Historical Results – National Averages

This State of Healthcare Quality Report classifies health plans differently than NCQA’s Quality Compass. HMO corresponds to All LOBs (excluding PPO and EPO) within Quality Compass. PPO corresponds to PPO and EPO within Quality Compass.

Figures do not account for changes in the underlying measure that could break trending. Contact Information Products via my.ncqa.org for analysis that accounts for trend breaks.