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Transitions of Care – Patient Engagement After Inpatient Discharge

Advantage MD, Provider Specialty: PCP, OCP. Members age 18 years and older

The percentage of acute and non-acute discharges, on or between January 1 and December 1 of the MY, for members 18 years of age and older.  Patient Engagement after Inpatient Discharge is one of the four rates reported for the TRC Measure.  Requires documentation of patient engagement (office visits, visits to the home, telehealth) provided within 30 days after discharge.

Best Practice and Measure Tips

Documentation in the outpatient medical record must include evidence of patient engagement within 30 days after discharge not including the discharge date. Any of the following meets criteria:    

  • Outpatient visit, including office visits and home visits. 
  • A telephone visit. A synchronous telehealth visit with real-time member-provider interaction using audio and video communication. 
  • E-visit or virtual check-in (asynchronous telehealth with two-way interaction, which was not real-time, between the member and provider). 
  • If member is unable to communicate with the provider, interaction between the member's caregiver and the provider meets criteria.   
  • Member engagement on the day of the discharge will not be compliant.
  • Documentation can come from any outpatient record that the primary care provider (PCP) or ongoing care provider can access.

Measure Exclusions

Required Exclusion: Hospice

Measure Codes

The following meet criteria for patient engagement: