Consensus Endorsed
Measures
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
Utilization
Cost
Readmission reduction measures selected from Key Quality Programs
Consensus measures were reviewed and endorsed by the TOC 2.0 SDOH Advisory 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: CTM-3 00767-01) |
| Evidence of high-risk medication assessment in elderly (NQF 0022) |
| Evidence of advance care planning documentation (CMS 00037-01MIPS, 00037-04BPCIA) |
| Evidence of bilateral exchange of necessary patient information (CHHQR 00728-05) |
| Evidence of longitudinal care management for patients at high risk for adverse health outcomes or risk (PARTC 00106-02c, MQRS 00106-01c) |
Transitions of Care
Funding and support for the Transitions of Care initiative is provided by