Product Lines:
Advantage MD, Dual Eligible Special Needs Plans (D-SNP), EHP, Priority Partners, and USFHP.

Measurement Period: January 1 - December 31
 
Description:
For persons 18 years of age and older, the risk-adjusted ratio of observed-to-expected unplanned acute readmissions (inpatient and observation stays) for any diagnosis within 30 days of an acute hospitalization (inpatient and observation stays).

Stratifications: 
Age as of the index discharge date for commercial and Medicaid. 

• 18–44 years.
• 45–54 years.
• 55–64 years.

Age as of the index discharge date for Medicare. 

• 18–44 years.
• 45–54 years.
• 55–64 years.
• 65–74 years.
• 75–84 years.
• 18–64 years.
• 85+ years.

Skilled nursing facility. Age as of the index discharge date (Medicare only).

• 65–74 years.
• 75–84 years.
• 85+ years.

Report Stratification by SES only for Advantage MD (Medicare product line).

Measure Reporting:
CMS Start Rating Measure. 

Improvement Notation:
Increased score indicates improvement.

Data Collection:

• Administrative.
  

Note: Supplemental data may only be used for the hospice exclusion.

Initial Population:

• Measure Item Count: Episode.
• Age:
  
  • Commercial and Medicaid: 18–64 years as of the index discharge date.
  • Medicare: 18 years and older as of the index discharge date.
• Gender/Sex criteria: 
  
  • Administrative Gender of Female (AdministrativeGender code female).
  • Administrative Gender of Male (AdministrativeGender code male).
• Benefits: Medical.
• Continuous Enrollment: 365 days prior to the index discharge date through 30 days after the index discharge date.
• Allowable Gap: 
  
  • 365 days to 1 day prior to the index discharge date: No more than one gap of ≤45 days. 
  • Index discharge date and 30 days following the index discharge date: None.

Definition: 
Direct transfer: When the discharge date from the initial stay precedes the admission date to a subsequent stay by 1 calendar day or less.

IHS - Index hospital stay: An acute inpatient or observation stay with a discharge on or between January 1 and December 1 of the measurement period, as identified in the denominator.

Index admission date: The HIS admission date.

Index Discharge Date: The IHS discharge date. The Index Discharge Date must occur on or between January 1 and December 1 of the measurement period.

Index Readmission Stay: An acute inpatient or observation stay for any diagnosis with an admission date within 30 days of a previous Index Discharge Date.

Index Readmission Date: The admission date associated with the Index Readmission Stay.

Planned hospital stay: A hospital stay is considered planned if it meets numerator exclusions criteria.

Plan population: Persons in the initial population prior to exclusion of outliers. The plan population is only used as a denominator for the outlier rate. Persons must be 18 years and older as of the earliest index discharge date. The plan population is based on persons, not on discharges. Person are only counted once in the plan population.

Outlier: 

• Medicaid and Medicare enrollees in the initial population with four or more IHS between January 1 and December 1 of the measurement period. 
• Commercial enrollees in the initial population with three or more IHS between January 1 and December 1 of the measurement period.

Non-outlier: 

• Medicaid and Medicare enrollees in the eligible population with three or fewer IHS between January 1 and December 1 of the measurement period. 
• Commercial enrollees in the eligible population with two or fewer IHS between January 1 and December 1 of the measurement period.

Skilled nursing care discharge: An index stay is discharged or transferred to skilled nursing care when the discharge date from the acute inpatient or observation stay precedes the admission date for skilled nursing care by 1 calendar day or less. 

Denominator:
Acute inpatient or observation stay discharges.
Acute inpatient and observation stay discharges on or between January 1 and December 1 of the measurement period.

Risk Adjustment Factors: 
Risk Adjustment Determination: For each IHS among non-outliers, identify risk adjustment weights based on observation stay status at discharge, surgeries, discharge condition, COVID-19 discharge, comorbidity, age and gender. Weights are specific to product line (Medicare Under 65, Medicare 65+, commercial, Medicaid).

Observation stay: The IHS at discharge was an observation stay.

Surgeries: The persons who underwent surgery during the stay. Consider an IHS to include a surgery if at least one procedure code is present from any provider between the admission and discharge dates. 

Discharge condition: Assign a discharge Clinical Condition (CC) category code or codes to the IHS based on its principal discharge diagnosis. For direct transfers, use the principal discharge diagnosis from the last discharge.

COVID-19 discharge: Assign a COVID-19 discharge code to the IHS if its principal discharge diagnosis was COVID-19 (ICD-10-CM code U07.1). For direct transfers, use the principal discharge diagnosis from the last discharge.

Comorbidities: All diagnoses for encounters during the 365 days prior to and on the date of the index discharge date. Include the following encounters:

• Outpatient visits, ED visits, telephone visits, nonacute inpatient encounters and acute inpatient encounters with a date of service in the period from 365 days before the index discharge date to (and including) the index discharge date. 
• Acute and nonacute inpatient discharges  with a discharge date in the period from 365 days before the index discharge date to (and including) the index discharge date.

Numerator:
At least one acute readmission for any diagnosis within 30 days of the index discharge date.
Acute inpatient and observation stays with an admission date on or between January 3 and December 31 of the measurement period. 

Best Practice and Measure Tips

• The denominator for this measure is based on discharges and not members specifically. 
• An acute discharge can be from any type of facility, including behavioral health facilities. 
• Discharges are excluded if a direct transfer takes place after Dec. 1 of the measurement year. 
• Please help members avoid readmission by: 
  • Implementing a robust, safe discharge plan that includes a post-discharge phone call within 3 days of discharge to perform medication reconciliation and follows with PCP/OCP as appropriate. During call discuss these questions:
    • Do you completely understand all the instructions you were given at discharge? 
    • Do you completely understand the medications and your medication instructions? Have you filled all new prescriptions? 
    • Have you made your follow-up appointments? Do you need help scheduling them? 
    • Do you have transportation to the appointment and/or do you need help arranging transportation? 
    • Do you have any questions? 
• A lower readmission rate and comprehensive diagnosis documentation will drive better scores for this measure. 
• Patients with multiple comorbidities are expected to return post inpatient or observation discharge at a higher rate. Ensure all suspect conditions are appropriately identified in the patient’s medical record and claims. 
• Discuss palliative care or hospice programs and assist with referral as appropriate.

Measure Exclusions

Denominator Exclusions:

• Persons in hospice or using hospice services any time during the measurement period.
• Exclude acute hospitalizations for the following reasons:
  • Person died during the inpatient stay.
  • A principal diagnosis of pregnancy or a condition originating in the perinatal period on the discharge claim. 
  • Exclude the hospital stay if the direct transfer’s discharge date occurs after December 1 of the measurement year.
  • Exclude hospital stays where the Index Admission Date is the same as the Index Discharge Date.

Numerator Exclusions:

Exclude acute hospitalizations with any of the following criteria on the discharge claim:

• A principal diagnosis of pregnancy or a condition originating in the perinatal period.
• A planned hospital stay using any of the following:
  
  • A principal diagnosis of maintenance chemotherapy. 
  • A principal diagnosis of rehabilitation. 
  • An organ transplant.
  • A potentially planned procedure without a principal acute diagnosis.