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HEDIS® 2022: What to Know About Transitions of Care

In its 2018 update to the Healthcare Effectiveness Data and Information Set (HEDIS®), the National Committee for Quality Assurance (NCQA) included a new measure: "Transitions of Care" (TRC). TRC remains one of the HEDIS® measures in 2022 — and a particularly important one given what we understand about the importance of transitions of care and the harmful gaps and errors that often occur during transitions.

6 Things to Know About the TRC HEDIS® Measure and Transitions of Care

Here are seven things you should know about the Transitions of Care HEDIS® measure, including changes made to the measure for HEDIS® 2022 reporting, and transitions of care in general.

1. Transitions of care meaning

What are transitions of care? A frequently cited definition comes from the American Geriatrics Society. It defines transitions of care as follows: "A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location." Representative locations include hospitals, sub-acute and post-acute nursing facilities, the patient's home, primary and specialty care offices, and long-term care facilities.

2. Description of the Transitions of Care HEDIS® measure

The current description of the HEDIS® TRC measure is as follows: "The percentage of discharges for members 18 years of age and older who had each of the following. Four rates are reported: 1) notification of inpatient admission; 2) receipt of discharge information; 3) patient engagement after inpatient discharge; and 4) medication reconciliation post-discharge (MRP)."

3. Describing TRC's reported rates

The following is how NCQA describes each of Transitions of Care HEDIS® measure's four reported rates:

  1. Notification of inpatient admission: Documentation of receipt of notification of inpatient admission on the day of admission through 2 days after the admission (3 total days).
  2. Receipt of discharge information: Documentation of receipt of discharge information on the day of discharge through 2 days after the discharge (3 total days)
  3. Patient engagement after inpatient discharge: Documentation of patient engagement (e.g., office visits, visits to the home, telehealth) provided within 30 days after discharge.
  4. Medication reconciliation post-discharge (MRP): Documentation of medication reconciliation on the date of discharge through 30 days after discharge (31 total days).

4. Changes to the HEDIS® TRC measure in 2022

There were six changes made to the Transitions of Care HEDIS® measure for measurement year (MY) 2022, according to the NCQA. Here are a few of the key revisions:

  • Clarified that members in hospice or using hospice services anytime during the MY are a required exclusion.
  • Added physician assistant as an appropriate provider type to perform a medication reconciliation for the medication reconciliation post-discharge indicator.
  • Clarified in the notes that documentation of "post-op/surgery follow-up" without a reference to "hospitalization," "admission," or "inpatient stay" does not meet criteria for the fifth bullet of the MRP indicator.

5. Intent of the HEDIS® TRC measure

When NCQA announced the addition of the Transitions of Care HEDIS® measure in 2018, it defined the measure's intent as follows: "This measure aims to improve care coordination during care transitions for at-risk populations including older adults and other individuals with complex health needs." This emphasizes NCQA’s measurements evolution to further support the PCMH model of care.

6. Applicable population for the TRC HEDIS® measure

The TRC measure applies only to the Medicare population. Note: HEDIS® measures can apply to one, two, or all of Medicare, Medicaid, and commercial plans.

7. Transitions of care as a Medicare Star rating

Transitions of care is not just a HEDIS® measure. It's also an active Medicare Part C Star rating and Medicare Part D Star rating.

Like the TRC HEDIS® measure, the TRC Star ratings also has a target population of 18 years and older.

The Star rating is described as follows: "The average of the rates for transitions of care – medication reconciliation post-discharge; transitions of care – notification of inpatient admission; transitions of care – patient engagement after inpatient discharge; and transitions of care – receipt of discharge information."

Why the HEDIS® Transitions of Care Measure Matters

In explaining why the TRC measure "matters," NCQA notes, "Transition from the inpatient setting back to home often results in poor care coordination, 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."

To gain an even better understanding of the importance of this measure, let's take a closer look at two of the four rates that must be reported and why they're so vital to quality of care.

Patient engagement after inpatient discharge

Much has been written about the risks associated with the period that follows discharge from a hospital. One frequently cited study determined that nearly 1 in 5 patients experience adverse events within just 3 weeks of discharge, with a majority of these events regarded as preventable or ameliorable.

As Vidhi Patel, PharmD, BCPS, a clinical pharmacist with Cureatr, noted in an interview, this period is a time when patients are most likely to be overwhelmed, frustrated, or experiencing any number of emotions associated with a health crisis. Such emotions can lead to transition gaps and treatment failures, which can ultimately contribute to patient harm and readmissions. Even when patients are provided correct instructions at discharge, there are no assurances they will fully understand what they must do.

Engaging with patients after discharge can do a world of good, Dr. Patel says. "As clinical pharmacists, we help bridge that gap and clarify concerns. … Sometimes patients feel a little forgotten following discharge. They've received all this attention in the hospital, but once they leave, they can feel alone, vulnerable, and overwhelmed. We help them in this moment of need by talking through their situation with them, providing guidance on their medications, and optimizing their pain management."

Medication reconciliation post-discharge (MRP)

Medication reconciliation post-discharge is not just one of the rates for the Transitions of Care HEDIS® measure. It's also its own HEDIS® measure, as well as a CMS quality measure.

The importance of consistently performing MRP cannot be understated. Consider these MRP statistics:

  • 40-50% of discharges do not have MRPs performed.
  • More than half of adults discharged leave with at least one medical error
  • More than 1 in 4 patients have an adverse drug reaction post-discharge
  • About 1 in 5 patients are readmitted due to adverse drug reactions

Furthermore, a quantitative literature review of studies examining medication reconciliation at discharge from a hospital found that between 20% and nearly 90% of patients encounter discrepancies at this time.

Consistent MRP can greatly improve patient safety, outcomes, and satisfaction while decreasing very costly readmissions. In fact, a random controlled trial at a hospital system demonstrated that there was a nearly 57% reduction in 30-day readmissions for congestive heart failure patients who received MRP performed by Cureatr clinical pharmacists.

Performing MRP can help with more than just medication reconciliation, as Tram Thai, PharmD, BCACP, AE-C, a Cureatr clinical pharmacist, recently noted. "The MRP is really just a baseline of the service. All the other issues that come to the surface when we're talking to the patient allow us to set the patient up for success in managing not only their medication but their overall health."

MRP Measure Reporting Cut Points

Cut points are the ranges from which Medicare Star Ratings are calculated. For the MRP measure, performance is based on the percentage of discharges from the reporting year for members 18 years of age and older for whom medications were reconciled within 30 days after the discharge. CMS cut points for MRP are as follows.

CMS cut points

Improving Transitions of Care With Cureatr

To learn how Cureatr is helping organizations nationwide improve their transitions of care and reduce the potential for harmful mistakes and gaps, schedule a consultation. A member of our team will walk you through how our combination of data, technology, and expert clinical services is making an impact for health plans, providers, and patients, and ultimately helping to solve the medication management puzzle.

Whitepaper: Medication Management Challenges and Opportunities for Payers and Providers


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