Transitions of Care (TRC)

Assesses key points of transition for Medicare beneficiaries 18 years of age and older after discharge from an inpatient facility. Four rates are reported:

  1. Notification of Inpatient Admission. Documentation in the medical record of receipt of notification of inpatient admission on the day of admission or the following day.
  2. Receipt of Discharge Information. Documentation in the medical record of receipt of discharge information on the day of discharge or the following day.
  3. Patient Engagement After Inpatient Discharge. Evidence of patient engagement (e.g., office visits, visits to the home, telehealth) provided within 30 days after discharge.
  4. Medication Reconciliation Post-Discharg Medication reconciliation on the date of discharge through 30 days after discharge (31 total days).

Why It Matters

Transition from the inpatient (hospital) setting back to home often results in poor care coordination, including communication lapses between inpatient and outpatient (a setting other than a hospital) providers; intentional and unintentional medication changes; incomplete diagnostic work-ups and inadequate patient, caregiver and provider understanding of diagnoses, medication and follow-up needs.1

One study estimated that inadequate care coordination and poor care transitions resulted in $25–$45 billion in unnecessary spending in 2011.2 With hospital stays costing the U.S. $377.5 billion per year and increased lengths of stay for Medicare beneficiaries, there is pressure for hospitals, health plans and providers to improve delivery and coordination of care and lower risks for these patients. This includes examining the admission and discharge processes to prevent rehospitalization, ED visits and other poor health outcomes.3

Results

Transitions of Care - Notification of Inpatient Admission - Total

YearMedicare HMOMedicare PPO
201816.613.8

Transitions of Care - Receipt of Discharge Information - Total

YearMedicare HMOMedicare PPO
201811.39.0

Transitions of Care - Patient Engagement after Inpatient Discharge - Total

YearMedicare HMOMedicare PPO
201853.450.4

Transitions of Care - Medication Reconciliation Post-Discharge - Total

YearMedicare HMOMedicare PPO
201853.450.4

References

  1. Rennke, S., O.K. Nguyen, M.H. Shoeb, Y. Magan, R.M. Wachter and S.R. Ranji. 2013. “Hospital-Initiated Transitional Care as a Patient Safety Strategy: A Systematic Review.” Annals of Internal Medicine 158(5, Pt. 2), 433–40.
  2. Health Affairs. 2012. Health Policy Brief: Care Transitions. September 13, 2012. http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_76.pdf (Accessed July 12, 2016)
  3. Health Catalyst. 2017. Patient-Centered LOS Reduction Initiative Improves Outcomes, Lowers Costs. https://downloads.healthcatalyst.com/wp-content/uploads/2016/06/Patient-Centered-LOS-Reduction-Initiative-Improves-Outcomes-Lowers-Costs.pdf (Accessed August 27, 2019)

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