After an inpatient hospitalization, appropriate and timely follow-up care is key to the overall successful treatment of patients. As this is vital to quality care, the National Committee for Quality Assurance (NCQA), has developed the Transitions of Care (TRC) measure as part of their HEDIS^® measure set. The TRC measure focuses on the percentage of members that receive timely continuity of care following an inpatient discharge. The four areas essential to a successful TRC include:

• Notification of Inpatient Admission (on the day of admission through 2 days after admission).
• Receipt of Discharge Information (on the day of discharge through 2 days after discharge).
• Patient Engagement after inpatient Admission (within 30 days of discharge but not on the day of discharge).
• Medication Reconciliation post-discharge (on the day of discharge through 30 days after discharge).

TRC is a heavily date driven measure with many specific criteria to meet compliance for each sub-measure. Understanding these criteria and time frames is key to success.

The Importance of Quality TRC

The transition from an inpatient setting back home can result in lapses in vital care for members due to poor care coordination and lack of communication between inpatient and outpatient providers. Inadequate care coordination and poor transitions of care results in billions of dollars of unnecessary spending annually. As a provider, you play a significant role in improving transitions of care. Whether it is providing excellent acute care during an inpatient stay or providing diligent follow-up management, each provider is key to the success of promoting the well-being of each patient. Timely documentation of this care is essential.

Challenges for the TRC Measure

• Despite its importance, the TRC measure is not without challenges. Primarily, the strict date timelines required by each sub-measure can be difficult to meet.
• Trends identified from previous TRC projects:
  • Notification of Inpatient Admission: Continues to be a challenge and is often not completed or signed within the measurement time frame.
  • Incomplete discharge information: One or more of the required elements is missing from the discharge documentation.
  • Patient Engagement and Medication Reconciliation: Completed but provider documentation time stamped or signed out of the measurement time frame.
  • Medication Reconciliation: Incomplete current medication lists contained in follow up notes.

Provider Best Practices

Inpatient Providers

• Identify primary care provider (PCP) or ongoing care provider (OCP) EARLY during hospitalization.
• Create templates and automatic notification systems within electronic health records (EHR) to help streamline documentation. For example, build a discharge template that requires the provider to address all six required elements needed for a compliant Receipt of Discharge Information sub-measure.
• Date, time stamp, and sign all notes within the measurement time frame.
• Ensure clear, concise documentation.

Outpatient Providers

• Request timely discharge summaries upon notification of inpatient discharge.
• Schedule follow up appointments with PCP/OCP ASAP. Keep in mind that the member must be seen before 30 days post discharge.
• Make sure documentation refers to the hospitalization, admission, or inpatient stay.
• Create templates within EHR to include the current medication list that requires the provider to review, sign, and time stamp within measurement time frame.
• Perform outreach to members to advise them of the importance of timely follow up.
• Consider obtaining an EHR that is linked to several of the large hospital systems in your area.
  • Shared EHRs help improve efficiency and optimize communication as well as offer a centralized place to store vital healthcare information.

  Bottom Line

  Coordination of care is important to ensure members receive the ongoing care they need and for providers to stay up to date on the members they are managing. Familiarizing yourself with measure requirements and automating key areas of provider documentation can help decrease provider burden while  increasing compliance for the Transitions of Care Measure.