The percentage of discharges from inpatient facilities for long-term services and supports (LTSS) organization members 18 years of age and older for whom a reassessment and care plan update occurred within 30 days of discharge.
The following rates are reported:
- Reassessment After Inpatient Discharge. The percentage of discharges from inpatient facilities resulting in an LTSS reassessment within 30 days of discharge.
- Reassessment and Care Plan Update After Inpatient Discharge. The percentage of discharges from inpatient facilities resulting in an LTSS reassessment and care plan update within 30 days of discharge.
Why It Matters
An inpatient stay may change what a member needs at home. People who use long-term services and supports (LTSS) may return home requiring different personal care assistance, home modifications, durable medical equipment, home health, meal or transportation assistance, or a different level of care altogether. When LTSS providers are not told that a member has been discharged and do not reassess, the care plan in place may no longer match the member’s actual needs.
The 2016 Medicaid and CHIP Managed Care Final Rule requires managed LTSS (MLTSS) programs to coordinate services between settings of care, including appropriate discharge planning for short-term and long-term hospital and institutional stays [1]. The 2024 Ensuring Access to Medicaid Services final rule also requires states to reassess functional need when an enrollee requests a reassessment or the enrollee’s circumstances change, in addition to reassessing at least every 12 months and reviewing the person-centered service plan annually [2]. An inpatient discharge is such a change in circumstances.
When people with multiple chronic conditions or disabilities do not receive transitional care support, they are more likely to receive duplicate services, experience medication errors and be rehospitalized [3]. In a randomized trial of community-dwelling older adults, care coordination with a transition coach reduced rehospitalization at 30 days (8.3 percent versus 11.9 percent) and at 90 days (16.7 percent versus 22.5 percent) and lowered mean hospital costs [4]. Transitions are also frequent for this population, and many members are discharged not directly home but to skilled nursing, inpatient rehabilitation or long-term care hospitals, each introducing another opportunity for information to be lost. Because Medicaid finances about half of national long-term care spending [5], timely reassessment and care plan updates after discharge are a high-value point of intervention.
Historical Results – National Averages
Performance results for this measure are currently unavailable.
References
- Centers for Medicare & Medicaid Services. 2016. “Medicaid and Children’s Health Insurance Program (CHIP) Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, and Revisions Related to Third Party Liability.” Federal Register 81, no. 88: 27497–901. https://www.federalregister.gov/d/2016-09581.
- Centers for Medicare & Medicaid Services. 2024. “Medicaid Program; Ensuring Access to Medicaid Services.” Federal Register 89, no. 92: 40542–874. https://www.federalregister.gov/d/2024-08363.
- Coleman, E.A., and R.A. Berenson. 2004. “Lost in Transition: Challenges and Opportunities for Improving the Quality of Transitional Care.” Annals of Internal Medicine 141, no. 7: 533–36.
- Coleman, E.A., C. Parry, S. Chalmers, and S.J. Min. 2006. “The Care Transitions Intervention: Results of a Randomized Controlled Trial.” Archives of Internal Medicine 166, no. 17: 1822–28.
- Hinton, E., E. Williams, J. Raphael, A. Mudumala, R. Rudowitz, K. Gifford, A. Lashbrook, C. Knapp, B. Kidder, and B. Snyder. 2023. “Amid Unwinding of Pandemic-Era Policies, Medicaid Programs Continue to Focus on Delivery Systems, Benefits, and Reimbursement Rates: Results from an Annual Medicaid Budget Survey for State Fiscal Years 2023 and 2024.” KFF. https://files.kff.org/attachment/EXECUTIVE-SUMMARY-50-State-Medicaid-Budget-Survey-for%20State-Fiscal-Years-2023-and-2024.pdf.
