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Johns Hopkins Health Plans

TRC - Transitions of Care Patient

Product Lines:
Advantage MD, Dual Eligible Special Needs Plans (D-SNP).

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

Definition:
The percentage of acute and non-acute discharges, on or between January 1st and December 1st of the MY, for members 18 years of age and older who had each of the four elements:

Acronyms:

  • OCP – Ongoing care provider
  • HIE - Health information exchange
  • ADT - Automated admission, discharge and transfer alert system

Continuous Enrollment:

  • The date of discharge through 30 days after discharge (31 days total). Member must be discharged to home on or by December 1st of the MY to remain in the measure.

Best Practice and measure Tips

Requirements:  Only EMR systems and medical records accessible to the PCP/OCP (ongoing care provider*) are eligible for use in reporting.  

  • Ensure all admission / discharge notifications are received and saved in the member’s outpatient chart.  Be sure to include any admission / discharge notifications from Skilled Nursing Facilities.  
  • Ensure appropriate engagement and medication reconciliation occur for all discharges including when discharged to home from Skilled Nursing Facilities.

*Ongoing care provider (OCP) - The practitioner who assumes responsibility for the member’s care. 

  • A provider/specialist may be considered an ongoing care provider if they provide care to the member in and out of the hospital. 
  • If the provider/specialist only provides care to the member in the hospital, then they are NOT considered an ongoing care provider. 
  • A provider/specialist who only sees the member outside the hospital MAY still be considered an ongoing care provider (e.g., if the member sees the provider before admission and then again after discharge; or if the member sees the provider regularly before admission but has no other visits for the rest of the measurement year after discharge). 
  • The provider/specialist is not required to perform the engagement visit in order to be considered an ongoing care provider. 
    • If the cardiologist or other specialist meets the criteria described above, then they may be considered an ongoing care provider and the outpatient medical record that is accessible to the cardiologist or other specialist may be used for all the TRC measure indicators. 
    • If the surgeon also sees the member outside of the hospital (i.e. they performed the pre-op exam and/or follow-up visit), then they may be considered to be the ongoing care provider. If the member only saw the surgeon while in the hospital then they may not be considered to be an OCP.

How admission and discharge dates are determined:

Members may be in the measure more than once in the measurement year. Each episode is determined based on the below:

  • An episode ends if the member remains discharged to home for 31 days.  Any admission after this would create a new Admission episode.
  • An episode continues when the first discharge is followed by a readmission or direct transfer to an acute or non-acute inpatient care setting on the date of discharge through 30 days after discharge (31 days total). 
  • Admit date = Date of the first admission 
  • Discharge date = Date of the discharge where there are no readmissions or direct transfers within the 31 days total.

Notification of Inpatient Admission:

Documentation sent to the member’s PCP or OCP must include dated evidence of receipt of notification of inpatient admission on the day of admission through 2 days after the admission (3 days total).

  • Compliance through Medical Record Review only. Ensure admission / discharge notifications are in member’s outpatient chart.
  • If member has an observation stay and then admitted as an inpatient, the date of the admission stay is used for compliance. Observation stays are considered outpatient.

Acceptable Criteria:

  • Communication between inpatient providers/staff and the member’s PCP/OCP via phone call/e-mail/fax.
  • Communication about admission between emergency department and the member’s PCP or OCP via phone call/e-mail/fax.
  • Communication about admission to the member’s PCP/OCP through HIE/ADT alert system/ shared EMR system.
  • Communication about admission with the member’s PCP or ongoing care provider through a shared electronic medical record (EMR) system.
    • NOTE: Received date is not required in a shared EMR system. We can utilize file date, date “in basket,” or date information was accessible (generated date) to PCP/OCP.
  • Communication about admission to the member’s PCP or ongoing care provider from the member’s health plan.
  • Member’s PCP/OCP admitted the member to the hospital.
  • Specialist admitted the member to the hospital and notified the member’s PCP/OCP.
  • PCP/OCP placed orders for tests and treatments during the member’s inpatient stay.
  • PCP/OCP performed a preadmission exam or received communication about a planned inpatient admission up to 30 days prior to surgery/admission date.
    • The planned admission documentation or preadmission exam must clearly pertain to the denominator event.

Not Acceptable:

  • Documentation that the member or the member’s family notified the member’s PCP or OCP of admission.
  • Documentation of notification that does not include a date when documentation was received or accessible to PCP or OCP.
  • Documentation which only references Provider sending the member to the ED.

Receipt of Discharge Information:

Documentation sent to the member’s PCP or OCP must include dated evidence of receipt of discharge information on the day of discharge through 2 days after the discharge (3 days total).

Note: Patients transferring from a hospital to a skilled nursing facility or other inpatient setting require notification of discharge from the skilled nursing facility or other inpatient setting.  This dated notification is required in the outpatient chart along with the below information in order to close the HEDIS gap.  

Discharge information may be included in, but not limited to, a discharge summary, summary of care record, or located in structured fields in an EMR.  

  • Discharge information must include ALL of the following:
    • The practitioner responsible for the member’s care during the inpatient stay.
    • Procedures or treatment provided.
    • Diagnoses at discharge.
    • Current medication list. 
    • Testing results, or documentation of pending tests or no tests are pending.
    • Instructions for patient care post-discharge.
  • Compliance through Medical Record Review only. Ensure admission / discharge notifications are saved in the member’s outpatient chart.

Acceptable Criteria:

  • Instructions for patient care post discharge given to the PCP, OCP, member, or family/caregiver.
  • Discharge instructions that direct the member to follow-up with the PCP.
  • Even when the PCP or OCP is the discharging provider, required discharge information must be documented in the appropriate medical record within timeframe.
  • “Received date” is not required in a shared EMR system. We can utilize “file date”, date “in the basket,’’ or date information was accessible (generated date) to PCP or OCP.

Not Acceptable:

  • Documentation the member or the member’s family notified the member’s PCP or OCP of discharge.
  • Documentation of notification that does not include a time frame or date when documentation received.

Patient Engagement After Inpatient Discharge:

Documentation of patient engagement (e.g., office visits, visits to the home, telehealth) provided within 30 days after discharge. If the member is unable to communicate with the provider, interaction between the member’s caregiver and the provider meets criteria. (HYBRID: Compliance via claims or Medical Record Review.)

Note: Patients transferring from a hospital to a skilled nursing facility or other inpatient setting require engagement after discharge from the skilled nursing facility or other inpatient setting.  

Easy Compliance with acceptable visit codes: (Add appropriate Medication Reconciliation Post-Discharge Code to Patient Engagement visit claim to meet medication reconciliation compliance.) 

Medication Reconciliation Post-Discharge:

Evidence discharge medications were reconciled with the most recent medication list in the PCP/OCP outpatient medical record on the date of discharge through 30 days after discharge (31 days total). (HYBRID: Compliance via claims or Medical Record Review).

Note: Patients transferring from a hospital to a skilled nursing facility or other inpatient setting DO NOT require medication reconciliation until they are discharged from the inpatient setting.

Documentation in the PCP / OCP’s outpatient medical record must include:

  • Evidence of medication reconciliation and the date when it was performed by either:
    • prescribing practitioner
    • clinical pharmacist
    • physician’s assistant
    • registered nurse 
  • Evidence the provider was aware of the hospitalization.  It is best practice to have both of the below in note:  
    • Mention of “hospitalization,” “admission” or “inpatient stay” in the note.
    • Reference to reconciliation of current and discharge medications in the note.
  • Only documentation in the outpatient chart meets the intent of the measure:
    • Provider or OCP speaks to member or caregiver via telephone and documents reference to hospitalization and medication reconciliation, which is documented in outpatient chart.
      • Example: “Conversation with patient after recent hospitalization (include date of admission / discharge). Reviewed discharge medications and reconciled with current medication list. Patient is aware of medication list.”
    • Care managers complete the MRP.
    • Be sure to include in documentation:
      • Reference to hospitalization with the dates of admission and D/C in case there are multiple admissions/ discharges.
      • Reference discharge medications reviewed and reconciled with current medication list. Patient aware of medication list.
      • Always include PCP/OCP name, EMR system, location, phone and fax.
      • Include where MRP was routed to (doctor/EMR).
      • Include any supporting documentation, which confirms PCP/OCP received and entered into member’s chart.
      • If documentation is faxed to PCP/OCP, request fax is shared with PCP/OCP and is added to member chart.
        • Example: “Transition of Care Medication Reconciliation Completed on (DATE) by (name). Conversation with (patient name / DOB) after recent hospitalization (include date of admission / discharge and facility discharged from if available). Reviewed discharge medications and reconciled with current medication list. Patient is aware of medication list. THIS COMMUNICATION MUST BE ADDED TO THE MEMBER’S OUTPATIENT CHART / EMR SYSTEM AS EVIDENCE OF MEDICATION RECONCILIATION POST DISCHARGE. Please save fax in member’s outpatient chart and have (provider name) review.

Acceptable Criteria:

  • Current medication list available & provider reconciled the current and discharge medications.
    • Mention of “hospitalization,” “admission” or “inpatient stay” in note is not required.
  • Current medications with a notation that references the discharge medications (e.g., no changes in medications since discharge, same medications at discharge, discontinue all discharge medications).
    • Mention of “hospitalization,” “admission” or “inpatient stay” in note is not required.
  • Current medications list available and discharge medications were reviewed.
    • Mention of “hospitalization,” “admission” or “inpatient stay” in note is not required.
  • Current medication list, discharge medication list are available and both lists were reviewed on the same date of service.
    • Mention of “hospitalization,” “admission” or “inpatient stay” in note is not required.
    • The act of documenting the medication list is considered evidence the provider reviewed the medications.
  • Current medications list available, member had post-discharge hospital follow-up and medications were reconciled/reviewed.
    • Documentation must indicate the provider was aware of the member’s hospitalization/discharge.
    • The act of documenting the medication list during a follow-up visit is considered evidence the provider reviewed the medications.
  • Discharge summary reads discharge medications were reconciled with the most recent medication list and it was filed (in the PCP/OCP’s outpatient chart) on the date of discharge through 30 days after discharge (31 total days).
    • There must be evidence that the discharge summary was filed in the PCP/OCP’s outpatient chart on the date of discharge through 30 days after discharge (31 total days).
    • Utilizing this discharge summary is the last resort, attempt to find documentation of an office visit, home visit (possibly RN), e-visit etc.
  • Notation that No medications were prescribed or ordered upon discharge.

Notes:

  • A medication list may include medication names only or may include medication names, dosages and frequency, over-the counter (OCT) medications, and herbal or supplemental therapies.
  • The Medication Reconciliation Post-Discharge sub-measure assesses whether medication reconciliation occurred, not the quality of the med list or the process used to reconcile the medications.

Not Acceptable:

  • Documentation of “post-op/surgery follow-up’’ without a reference to “hospitalization”, “admission” or “inpatient stay’’ does not imply there was a hospitalization and is not considered evidence that the provider was aware of the hospitalization.
  • Documentation indicating only that the provider was aware of the surgery (even if the procedure/surgery is typically performed inpatient) or if the provider performed the surgery is not sufficient to show that the provider was aware of the “hospitalization” at the time of the follow-up visit. (NCQA Response 4/2023)
  • The presence of a discharge notification or discharge summary in the medical record alone does not count as evidence that the provider was aware of the hospitalization at the time of the follow-up visit (even if the provider was the discharging provider). (NCQA response 4/2023)

Easy Compliance with acceptable codes: (Add appropriate Medication Reconciliation Post-Discharge Code to Patient Engagement visit to meet MRP compliance.)

Measure Exclusions

Required Exclusions:

  • Members in hospice or using hospice services anytime during the measurement year.
  • Members who died any time during the measurement year.

Measure Codes

Patient Engagement After Inpatient Discharge Patient Engagement.

  • An outpatient visit, telephone visit, e-visit or virtual check-in:
    • CPT: 98966, 98967, 98968, 98970, 98971, 98972, 98980, 98981, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99421, 99422, 99423, 99429, 99441, 99442, 99443, 99455, 99456, 99457, 99458, 99483
    • HCPCS: G0071, G0402, G0438, G0439, G0463, G2010, G2012, G2250, G2251, G2252, T1015**
      • NOTE: **T1015 HCPCS code which identifies an all-inclusive clinic visit for services rendered at a Federally Qualified Health Center (FQHC)
    • UBREV: 0510, 0511, 0512, 0513, 0514, 0515, 0516, 0517, 0519, 0520, 0521, 0522, 0523, 0526, 0527, 0528, 0529, 0982, 0983
  • Transitional care management: CPT:99495, 99496

Medication Reconciliation Post-Discharge.

  • Medication Reconciliation Encounter CPT: 99483, 99495, 99496
  • Medication Reconciliation Intervention CPT-II: 1111F