Transitions of Care Measurement Guidelines

This document is a guide that outlines the measurement criteria for Transitions of Care (TRC) applicable to Medicare patients. It describes the percentage of discharges for patients aged 18 and older who experienced an inpatient discharge within the measurement year. The guide specifies four essential components that must be documented in the outpatient medical records: notification of inpatient admission, receipt of discharge information, patient engagement after discharge, and medication reconciliation post-discharge. Each component has defined timing and documentation requirements to ensure compliance. Additionally, the document details exclusions for patients who received hospice care during the measurement year. It emphasizes the importance of proper documentation and communication between healthcare providers and patients to facilitate effective transitions of care and reduce readmission rates. The guide also includes tips for successful implementation, such as using computerized order entry systems and developing standardized post-discharge communication protocols.