Consensus Endorsed



The Executive Steering Committee identified 9 consensus measures which will assess outcomes associated with implementation of the Transitions of Care Standards. 

Consensus Measures

4 Process Measures:

Selected from Healthcare Effectiveness Data and Information Set (HEDIS) Care Transition Measures

5 Outcome Measures: 

Patient safety

Patient experience



Readmission reduction measures selected from Key Quality Programs

Broad Experience

Consensus measures have been reviewed and endorsed by the ACMA Transitions of Care Executive Steering committee comprised of subject matter experts with a broad range of experience.

Process Measures (HEDIS) - Measures Performance

Evidence of inpatient admission documentation to primary care provider
Evidence of receipt of discharge information on the day of discharge or the following day
Evidence of patient engagement (office, home, telehealth visits) provided within 30 days after discharge
Evidence of medication reconciliation on date of discharge

Outcome Measures (Varied Programs) - Measures Impact

Evidence of completion of a health risk assessment (CMS: IQR/OQR 2624)
Evidence of high risk medication assessment in elderly (CMS IQR/OQR 0022)
Evidence of advance care planning documentation (CMS 0326)
Evidence of bilateral exchange of necessary patient information (CMS IA_CC_13)
Evidence of longitudinal care management for patients at high risk for adverse health outcomes or risk (CMS IA_PM_14)

Transitions of Care

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Sponsored by

Funding and support for the Transitions of Care initiative is provided by Pfizer.