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HEDIS Transitions of Care measure: How CarePort Can Help Health Plans

In February, CMS’s 2021 Medicare Advantage and Part D Advance Notice (Part II) outlined proposed changes to the Medicare program for Measurement Year (MY) 2022, including modifications to the Medicare Advantage Star Ratings program and the addition of the HEDIS (Healthcare Effectiveness Data and Information Set) Transitions of Care (TRC) measure from the National Committee for Quality Assurance (NCQA). At present, the measure has been proposed for addition beginning in MY 2022, but while CMS hasn’t finalized its addition to the Medicare Advantage Program, or a date for its addition, it’s important to start thinking about how to implement tools to help now. 

HEDIS Transitions of Care Measure

The HEDIS Transitions of Care measure, currently a display measure, incorporates time-sensitive elements known to mitigate readmission risk. NCQA has prioritized the inpatient to home transition because it often results in poor outcomes – including communication lapses between inpatient and outpatient providers, intentional and unintentional medication changes, incomplete diagnostic work-ups and inadequate patient, caregiver and provider understanding of diagnoses, medication and follow-up needs.

HEDIS Transitions of Care Notification Requirements

The HEDIS TRC measure requires four actions, outlined below, to occur for each inpatient admission of Medicare beneficiaries:

  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-discharge: Medication reconciliation on the date of discharge through 30 days after discharge (31 total days)

How Can CarePort Help Payers?

Two of the required actions pertain to notification of inpatient admissions and discharges to the patient’s ongoing care provider in near real-time. Via real-time data exchange and alerts, CarePort enables care management teams to locate and track patients after discharge – and contact a patient’s next provider – to ensure each patient receives high-quality care post-discharge, regardless of where that care is received.

Leveraging the CarePort platform, plans can experience improved outcomes and reduced readmissions, as well as improved Plan All-Cause Readmission (PCR) HEDIS measure scores. These discharge notifications also enable providers to proactively schedule post-discharge inpatient and emergency department (ED) follow-up visits.

This is the first post in our series covering proposed changes to the Medicare Advantage Star Ratings program. Stay tuned for our next blog, which will discuss readmissions reduction. 

Is your organization prepared to succeed under the HEDIS TRC measure, in proposed revisions to the Star Ratings program? Don’t wait until it’s too late – reach out and learn how CarePort can help.

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