Mount Carmel Health Partners HEDIS Tip Sheets - Page 25

Transitions of Care (TRC) (continued) planned admission prior to the admit date also meets criteria. The planned admission documentation or preadmission exam must clearly pertain to the denominator event. Receipt of Discharge Information  Documentation of receipt of discharge information on the day of discharge or the following day.  Documentation must include evidence of receipt of discharge information on the day of discharge or the following day. Discharge information may be included in a discharge summary or summary of care record or be located in structured fields in an EHR. At a minimum, the discharge information should include ALL of the following: o The practitioner responsible for the member’s care during the inpatient stay o Procedures or treatment provided o Diagnoses at discharge o Current medication list (including allergies) o Testing results, or documentation of pending tests or no tests pending o Instructions to the PCP or ongoing care provider for patient care Patient Engagement On or after Inpatient Discharge  Documentation of patient engagement (e.g., office visits, visits to the home, or telehealth) provided within 30 days on or after discharge. o (Do not include patient engagement that occurs on the date of discharge.)  Either of the following may be used: - o An outpatient visit, including office visits and home visits – o A synchronous telehealth visit where real-time interaction occurred between the member and provider via telephone or videoconferencing. Medication Reconciliation Post-discharge Medication reconciliation conducted by a prescribing practitioner, clinical pharmacist or registered nurse on the date of discharge through 30 days on or after discharge (31 total days).  Documentation in the outpatient medical record must include evidence of reconciliation and the date it was performed.  Any of the following may be used: o Documentation of the current medications with a notation that the provider reconciled the current and discharge medications o Documentation of the current medications with a notation that references the discharge medications (e.g., no changes in medications since discharge, same medications at discharge, discontinue all discharge medications) o Documentation of the member’s current medications with a notation that the discharge medications were reviewed o Documentation of a current medication list, a discharge medication list and notation that both lists were reviewed on the same date of service o Documentation of the current medications with evidence that the member was seen for post- discharge hospital follow-up with evidence of medication reconciliation or review o Documentation in the discharge summary that the discharge medications were reconciled with the most recent medication list in the outpatient medical record. There must be evidence that the o 25