Product Lines:
Advantage MD, Dual Eligible Special Needs Plans (D-SNP), EHP, Priority Partners, and USFHP.

Eligible Population:
Members 18 years of age and older as of December 31 of the measurement year.

Definition:
For members 18 years of age and older, the number of acute inpatient and observation stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission.

For commercial (EHP & USFHP) and Medicaid (Priority Partners), 18–64 years as of the Index Discharge Date.

For Medicare (Advantage MD), 18 years and older as of the Index Discharge Date.

IHS: Index hospital stay. An acute inpatient or observation stay with a discharge on or between January 1 and December 1 of the measurement year, as identified in the denominator.

Index Discharge Date: The IHS discharge date. The Index Discharge Date must occur on or between January 1 and December 1 of the measurement year.

Index Readmission Stay: An acute inpatient or observation stay for any diagnosis with an admission date within 30 days of a previous Index Discharge Date.

Index Readmission Date: The admission date associated with the Index Readmission Stay.

Note: Per General Guideline Members With Dual Enrollment, members with dual commercial and Medicaid enrollment may only be reported in the commercial product line. Members with dual Medicaid/Medicare enrollment “dual eligible” and with Medicare-Medicaid (MMP) enrollment may only be reported in the Medicare product line.

Continuous Enrollment:

• 365 days prior to the Index Discharge Date through 30 days after the Index Discharge Date.

Best Practice and Measure Tips

• The denominator for this measure is based on discharges and not members specifically. 
• An acute discharge can be from any type of facility, including behavioral health facilities. 
• Discharges are excluded if a direct transfer takes place after Dec. 1 of the measurement year. 
• Please help members avoid readmission by: 
  • Implementing a robust, safe discharge plan that includes a post-discharge phone call within 3 days of discharge to perform medication reconciliation and follows with PCP/OCP as appropriate. During call discuss these questions:
    • Do you completely understand all the instructions you were given at discharge? 
    • Do you completely understand the medications and your medication instructions? Have you filled all new prescriptions? 
    • Have you made your follow-up appointments? Do you need help scheduling them? 
    • Do you have transportation to the appointment and/or do you need help arranging transportation? 
    • Do you have any questions? 
• A lower readmission rate and comprehensive diagnosis documentation will drive better scores for this measure. 
• Patients with multiple comorbidities are expected to return post inpatient or observation discharge at a higher rate. Ensure all suspect conditions are appropriately identified in the patient’s medical record and claims. 
• Discuss palliative care or hospice programs and assist with referral as appropriate.

Measure Exclusions

• Members in hospice or using hospice services anytime during the measurement year.
• Exclude acute hospitalizations for the following reasons:
  • Member died during the inpatient stay
  • Member with a principal diagnosis of pregnancy on the discharge claim
  • Principal diagnosis of a condition originating in the perinatal period on the discharge claim
  • Planned admissions for:
    • Chemotherapy maintenance
    • Principle diagnosis of rehabilitation
    • Organ transplant
    • Potentially planned procedure without a principal acute diagnosis
  • Exclude the hospital stay if the direct transfer’s discharge date occurs after December 1 of the measurement year.
  • Exclude hospital stays where the Index Admission Date is the same as the Index Discharge Date.