NQF

Agenda Synopsis

Full Agenda

Measure Index

• Transfer of Health Information to Provider—Post-Acute Care (Public comments received:7; MUC ID: MUC2018-131)
  
  
• Transfer of Health Information to Patient—Post-Acute Care (Public comments received:6; MUC ID: MUC2018-135)
  
  

• Transitions from Hospice Care, Followed by Death or Acute Care (Public comments received:5; MUC ID: MUC2018-101)
  
  

• Transfer of Health Information to Provider—Post-Acute Care (Public comments received:7; MUC ID: MUC2018-132)
  
  
• Transfer of Health Information to Patient—Post-Acute Care (Public comments received:6; MUC ID: MUC2018-139)
  
  

• Transfer of Health Information to Provider—Post-Acute Care (Public comments received:5; MUC ID: MUC2018-133)
  
  
• Transfer of Health Information to Patient—Post-Acute Care (Public comments received:5; MUC ID: MUC2018-141)
  
  

• Transfer of Health Information to Provider—Post-Acute Care (Public comments received:4; MUC ID: MUC2018-136)
  
  
• Transfer of Health Information to Patient—Post-Acute Care (Public comments received:6; MUC ID: MUC2018-138)
  
  

Full Measure Information

Measure Specifications

• NQF Number (if applicable):
  
  
• Description: The purpose of this measure is to assess for and report on the timely transfer of health information when a patient is discharged from their current setting of care. For this measure, the timely transfer of health information specifically assesses for the transfer of the patient’s current reconciled medication list. This process measure calculates the proportion of patient/resident stays or quality episodes with a discharge/transfer assessment indicating that a current reconciled medication list was provided to the subsequent provider at the time of discharge/transfer.
  
  
• Numerator: HHA: The numerator is the number of home health quality episodes with an OASIS discharge/transfer assessment indicating a current reconciled medication list was provided to the subsequent provider at the time of discharge/transfer.
  
  
• Denominator: HHA Denominator: The denominator for this measure is the number of Medicare Part A, Medicare Part B, Medicare Advantage (Part C) and Medicaid covered home health quality episodes ending in discharge/transfer to the following settings only: a short-term general hospital, a SNF, intermediate care, home under care of another organized home health service organization or hospice, hospice in an institutional facility, a swing bed, an IRF, a LTCH, a Medicaid nursing facility, an inpatient psychiatric facility, or a critical access hospital.
  
  
• Exclusions: Patients who died are not included in this measure
  
  
• HHS NQS Priority: Promote Effective Communication & Coordination of Care
  
  
• HHS Data Source: OASIS
  
  
• Measure Type: Process
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status:
  
  
• Meaningful Measure Area: Transfer of Health Information and Interoperability
  
  
• Changes to Endorsed Measure Specifications?:
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Conditional Support Pending NQF Endorsement
  
  
• Preliminary analysis summary
  • Contribution to program measure set:This measure could help improve the transfer of information about a patient’s medication, an important aspect of care transitions. Better care transitions could improve patient outcomes, reduce complications, and lessen the risk of hospital admissions or readmissions.
  • Impact on quality of care for patients:This measure would meet an IMPACT Act requirement, address PAC/LTC core concepts not currently included in the program measure set, and promote alignment across programs.
  
  
  
• Does the measure address a critical quality objective not currently adequately addressed by the measures in the program set? Yes. This measure was developed to meet a requirement of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. While the HHQR measure set includes some related measures addressing readmissions, drug regimen review, and drug education for patients, it does not currently address the transfer of information across sites of care. The effective and timely transfer is an important aspect of care coordination. Specifically, this measure addresses the transfer of medication information. Patients in post-acute and long-term settings are more likely to have multiple conditions, requiring multiple medications, and to transition across settings and provider. Improved communication about medication regimens is an important element of care transitions for post-acute and long-term care patients. [1, 2] Improved care transitions could results in fewer complications and readmissions. 1. Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271.2. Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812.
  
  
• Is the measure evidence-based and either strongly linked to outcomes or an outcome measure? Yes. Missing or incomplete information on a patient’s medications has been associated with an increased risk of hospital admission and can be a serious safety risk. [1,2,3,4,5,6] Moreover, improving communication between provider about a patient’s medication regimen has been found to be a key factor to improving care transitions and reducing harm to patients. [7,8] Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between discharging/ transferring and receiving providers, including medication information. [9,10,11] Kwan, J. L., Lo, L., Sampson, M., & Shojania, K. G. (2013). Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Annals of Internal Medicine, 158(5), 397-403.Boockvar, K. S., Blum, S., Kugler, A., Livote, E., Mergenhagen, K. A., Nebeker, J. R., & Yeh, J. (2011). Effect of admission medication reconciliation on adverse drug events from admission medication changes. Archives of Internal Medicine, 171(9), 860-861.Bell, C. M., Brener, S. S., Gunraj, N., Huo, C., Bierman, A. S., Scales, D. C., & Urbach, D. R. (2011). Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA, 306(8), 840-847.Basey, A. J., Krska, J., Kennedy, T. D., & Mackridge, A. J. (2014). Prescribing errors on admission to hospital and their potential impact: a mixed-methods study. BMJ Quality & Safety, 23(1), 17-25.Desai, R., Williams, C. E., Greene, S. B., Pierson, S., & Hansen, R. A. (2011). Medication errors during patient transitions into nursing homes: characteristics and association with patient harm. The American Journal of Geriatric Pharmacotherapy, 9(6), 413-422.Boling, P.A. (2009). Care transitions and home health care. Clinical Geriatric Medicine Feb;25(1):135-48.Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271.Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812.U.S. Agency for Healthcare Research and Quality. (2016). National healthcare quality and disparities report chartbook on care coordination (Pub. No. 16-0015-6-EF). Rockville, MD: Agency for Healthcare Research and Quality.Murray, L. M., & Laditka, S. B. (2010). Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research. Journal of the American Medical Directors Association, 11(4), 231-238.LaMantia, M. A., Scheunemann, L. P., Viera, A. J., Busby, Whitehead, J., & Hanson, L.C. (2010). Interventions to improve transitional care between nursing homes and hospitals: a systematic review. Journal of the American Geriatrics Society, 58(4), 777-782.
  
  
• Does the measure address a quality challenge? Yes. Although the transfer of a patient’s discharge medication information to their next provider and to the patient is a common practice and is part of the discharge planning requirements for participation in Medicare and Medicaid programs, the included information can vary and is not standardized and information is often sent as a as a hard copy, rather than electronically to the recipient’s EHR system or through interoperable exchange. This measure aims to standardize the medication information transferred to providers, and, to increase the electronic transfer of medication information.
  
  
• Does the measure contribute to efficient use of measurement resources and/or support alignment of measurement across programs? Yes. This measure addresses the transfer of health information across sites of care, a concept not currently addressed by measures in the set. Additionally, this measure would support an IMPACT Act requirement and would support measurement across PAC and LTC settings.
  
  
• Can the measure can be feasibly reported? Yes. The measure is calculated using OASIS data from for HHA patients. Additionally, pilot testing has shown high rates of inter-rater reliablity and debriefing interviews found that the measure can be feasibily reported. However, during a recent public comment period on the measure, commenters expressed concern about the ability of PAC providers to transfer the medication list electronically through their EHRs/EMRs, noting concenrs about rate of adoption of EHRs in PAC settings, limited participation in health information exchange (HIE), and how the lack of adoption universally impacts their ability to transfer the information electronically. Commenters also noted the challenges resulting from the lack of standards around medication information exchange. [1]This measure were previously reviewed by MAP and recommended to be refined and resubmitted due to concerns about feasibility and validity. [2] The developer has made several updates to address MAP’s concerns. First, the attribution of the measure has been changed to place accountability on discharging provider rather than the receiving provider. Secondly, the revised version of the measure providers includes a minimum set of patient information that must be transferred rather than the preivous measure which only specified that at least one information type was transferred. 1. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/IMPACT-Medication-Profile-Transferred-Public-Comment-Summary-Report.pdf2. MAP 2017 Considerations for Implementing Measures in Federal Programs:Post-Acute Care and Long-Term Care
  
  
• Is the measure applicable to and appropriately specified for the program's intended care setting(s), level(s) of analysis, and population(s)? Yes. Yes, the measure is specified for the home health setting and the facility level of analysis.
  
  
• Measure development status: Field Testing
  
  
• If the measure is in current use, have negative unintended issues to the patient been identified? N/A. This measure has not been implemented yet.
  
  
• If the measure is in current use, have implementation challenges outweighing the benefits of the measure have been identified? N/A. This measure has not been implemented yet.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted.
  
  
• PAC/LTC core competency addressed by the measure: This measure addresses several MAP PAC/LTC core concepts including effective transitions of care, accurate transmission of information, and adverse drug events.
  
  
• IMPACT Act Domain addressed by the measure: The IMPACT Act requires a quality measure under the domain of the transfer of health information and care preferences when an individual transitions between post-acute care
  
  

Rationale for measure provided by HHS
The communication of health information, such as that of a medication list, is critical to ensuring safe and effective patient transitions from one health care setting to another. The focus of this measure is the timely communication of health information, such as medication information at PAC discharge/transfer. Health information that is incomplete or missing, such as medication information, increases the likelihood of a patient/resident safety risk, often life-threatening. [1,2,3,4,5,6] Older adults are particularly vulnerable to adverse health outcomes due to insufficient medication information on the part of their health care providers, and their higher likelihood for multiple comorbid chronic conditions, polypharmacy, and complicated transitions between care settings. [7, 8]. Hospitalized patients discharged to SNFs had an average of 13 medications on their hospital discharge list [9], thus SNF and other PAC providers often are in the position of starting complex new medication regimens with little knowledge of the patient or their medication history. Furthermore, medication discrepancies are common, and found to occur in as many as three quarters of SNF admissions and 86 percent of all transitions.[10,11] Older patients being discharged to settings other than their home were more likely to experience a medication discrepancy, increasing their likelihood of experiencing an adverse event. [12] PAC patients often have complicated medication regimens and require efficient and effective communication and coordination of care between settings, including detailed transfer of medication information. Inter-institutional communication regarding medication regimens is a key factor to improving care transitions and reducing harm to patients. [13,14] Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between discharging/ transferring and receiving providers, including medication information. [15,16,17] A comprehensive medication list is an important means of communication this information. The transfer of the patient’s discharge medication information to their next providers and to the patients, in the form of a medication list, is common practice, and supported by discharge planning requirements for participation in Medicare and Medicaid programs. Most PAC EHR systems generate a discharge medication list. However, the content included in the medication lists varies and are not standardized. Other critical medication information may not be included in the medication lists provided at care transitions. Furthermore, these lists are often sent as a hard copy, rather than electronically to the recipient’s EHR system or through interoperable exchange. A pharmacist study identified multiple opportunities to optimize nursing facility discharge medication lists in order to increase patient safety and potentially reduce readmissions. [18]. They noted that nursing facility settings have not made many improvements in discharge medication lists as hospitals have. The pharmacists also identified ideal components of a SNF discharge facility list, including an electronic medication list to minimize human error. An objective of this measure is to improve and standardize the type of medication list information transferred to providers, and, to increase, over time, the secure, timely, electronic transfer of the reconciled medication list using HIT standards. PAC provider adoption of EHRs and participation in health Information exchange can reduce provider burden through the use and reuse of healthcare data, and supports high quality, personalized, and efficient healthcare, care coordination and person-centered care. Further, the interoperability provisions of the 21st Century Cures Act provide a strong framework to enable electronic sharing and interoperable exchange of medication list information. 1. Kwan, J. L., Lo, L., Sampson, M., & Shojania, K. G. (2013). Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Annals of Internal Medicine, 158(5), 397-403. 2. Boockvar, K. S., Blum, S., Kugler, A., Livote, E., Mergenhagen, K. A., Nebeker, J. R., & Yeh, J. (2011). Effect of admission medication reconciliation on adverse drug events from admission medication changes. Archives of Internal Medicine, 171(9), 860-861. 3. Bell, C. M., Brener, S. S., Gunraj, N., Huo, C., Bierman, A. S., Scales, D. C., & Urbach, D. R. (2011). Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA, 306(8), 840-847. 4. Basey, A. J., Krska, J., Kennedy, T. D., & Mackridge, A. J. (2014). Prescribing errors on admission to hospital and their potential impact: a mixed-methods study. BMJ Quality & Safety, 23(1), 17-25. 5. Desai, R., Williams, C. E., Greene, S. B., Pierson, S., & Hansen, R. A. (2011). Medication errors during patient transitions into nursing homes: characteristics and association with patient harm. The American Journal of Geriatric Pharmacotherapy, 9(6), 413-422. 6. Boling, P.A. (2009). Care transitions and home health care. Clinical Geriatric Medicine Feb;25(1):135-48. 7. Chhabra, P. T., Rattinger, G. B., Dutcher, S. K., Hare, M. E., Parsons, K., L., & Zuckerman, I. H. (2012). Medication reconciliation during the transition to and from long-term care settings: a systematic review. Res Social Adm Pharm 8(1), 60-75. 8. Levinson, D. R., & General, I. (2014). Adverse events in skilled nursing facilities: national incidence among Medicare beneficiaries. Washington, DC: U.S. Department of Health and Human Services, Office of the Inspector General. 9. Bell, S. P., Vasilevskis, E. E., Saraf, A. A., Jacobsen, J. M. L., Kripalani, S., Mixon, A. S., ... & Simmons, S. F. (2016). Geriatric syndromes in hospitalized older adults discharged to skilled nursing facilities. Journal of the American Geriatrics Society, 64(4), 715-722. 10. Tjia, J., Bonner, A., Briesacher, B. A., McGee, S., Terrill, E., Miller, K. (2009). Medication discrepancies upon hospital to skilled nursing facility transitions. J Gen Intern Med, 24(5), 630-635. 11. Sinvani, L. D., et al. (2013). Medication reconciliation in continuum of care transitions: a moving target. J Am Med Dir Assoc, 14(9), 668-672 12. Manias, E., Annaikis, N., Considine, J., Weerasuriya, R., & Kusljic, S. (2017). Patient-, medication- and environment-related factors affecting medication discrepancies in older patients. Collegian, 24, 571-577. 13. Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271. 14. Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812. 15. U.S. Agency for Healthcare Research and Quality. (2016). National healthcare quality and disparities report chartbook on care coordination (Pub. No. 16-0015-6-EF). Rockville, MD: Agency for Healthcare Research and Quality. 16. Murray, L. M., & Laditka, S. B. (2010). Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research. Journal of the American Medical Directors Association, 11(4), 231-238. 17. LaMantia, M. A., Scheunemann, L. P., Viera, A. J., Busby-Whitehead, J., & Hanson, L.C. (2010). Interventions to improve transitional care between nursing homes and hospitals: a systematic review. Journal of the American Geriatrics Society, 58(4), 777-782. 18. Backes, A.C., Cash, P., &Jordan, J. (2016). Optimizing the use of discharge medication lists in nursing facilities. Consult Pharm, 31, 493-499.

Measure Specifications

• NQF Number (if applicable):
  
  
• Description: The purpose of this measure is to assess for and report on the timely transfer of health information when a patient is discharged from their current setting of care. For this measure, the timely transfer of health information specifically assesses for the transfer of the patient’s current reconciled medication list. This process measure calculates the proportion of patient/resident stays or quality episodes with a discharge/transfer assessment indicating that a current reconciled medication list was provided to the patient, family and/or caregiver at the time of discharge/transfer.
  
  
• Numerator: HHA: The numerator is the number of home health quality episodes with an OASIS discharge/transfer assessment indicating a current reconciled medication list was provided to the patient, family and/or caregiver at the time of discharge/transfer.
  
  
• Denominator: HHA Denominator: The denominator for this measure is the number of Medicare Part A, Medicare Part B, Medicare Advantage (Part C) and Medicaid covered home health quality episodes ending in discharge or transfer to the following settings only: a private home/ apartment (apt.), board/care, assisted living, group home, transitional living or home under care of organized home health service organization or hospice.
  
  
• Exclusions: Patients who died are not included in this measure.
  
  
• HHS NQS Priority: Promote Effective Communication & Coordination of Care
  
  
• HHS Data Source: OASIS
  
  
• Measure Type: Process
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status:
  
  
• Meaningful Measure Area: Transfer of Health Information and Interoperability
  
  
• Changes to Endorsed Measure Specifications?:
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Conditional Support Pending NQF Endorsement
  
  
• Preliminary analysis summary
  • Contribution to program measure set:This measure could help improve the transfer of information about a patient’s medication elements, an important aspect of care transitions. Better care transitions could improve patient outcomes, reduce complications, and lessen the risk of hospital admissions or readmissions.
  • Impact on quality of care for patients:This measure would meet an IMPACT Act requirement, address PAC/LTC core concepts not currently included in the program measure set, and promote alignment across programs.
  
  
  
• Does the measure address a critical quality objective not currently adequately addressed by the measures in the program set? Yes. Yes, while the HHQR measure set includes some related measures addressing readmissions, drug regimen review, and drug education for patients, it does not currently address the transfer of information across sites of care. The effective and timely transfer is an important aspect of care coordination. Patients in post-acute and long-term settings are more likely to have multiple conditions, requiring multiple medications, and to transition across settings and provider. Improved communication about medication regimens is an important element of care transitions for post-acute and long-term care patients. [1, 2] Improved care transitions could results in fewer complications and readmissions. Specifically, this measure addresses the transfer of medication information to the patient, family and/or caregiver. This measure would address patient and family education and could help patients and caregivers to take a more active role in their care. 1. Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271.2. Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812.
  
  
• Is the measure evidence-based and either strongly linked to outcomes or an outcome measure? Yes. Missing or incomplete information on a patient’s medications has been associated with an increased risk of hospital admission and can be a serious safety risk. [1,2,3,4,5,6] Moreover, improving communication between provider about a patient’s medication regimen has been found to be a key factor to improving care transitions and reducing harm to patients. [7,8] Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between discharging/ transferring and receiving providers, including medication information. [9,10,11] Kwan, J. L., Lo, L., Sampson, M., & Shojania, K. G. (2013). Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Annals of Internal Medicine, 158(5), 397-403.Boockvar, K. S., Blum, S., Kugler, A., Livote, E., Mergenhagen, K. A., Nebeker, J. R., & Yeh, J. (2011). Effect of admission medication reconciliation on adverse drug events from admission medication changes. Archives of Internal Medicine, 171(9), 860-861.Bell, C. M., Brener, S. S., Gunraj, N., Huo, C., Bierman, A. S., Scales, D. C., & Urbach, D. R. (2011). Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA, 306(8), 840-847.Basey, A. J., Krska, J., Kennedy, T. D., & Mackridge, A. J. (2014). Prescribing errors on admission to hospital and their potential impact: a mixed-methods study. BMJ Quality & Safety, 23(1), 17-25.Desai, R., Williams, C. E., Greene, S. B., Pierson, S., & Hansen, R. A. (2011). Medication errors during patient transitions into nursing homes: characteristics and association with patient harm. The American Journal of Geriatric Pharmacotherapy, 9(6), 413-422.Boling, P.A. (2009). Care transitions and home health care. Clinical Geriatric Medicine Feb;25(1):135-48.Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271.Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812.U.S. Agency for Healthcare Research and Quality. (2016). National healthcare quality and disparities report chartbook on care coordination (Pub. No. 16-0015-6-EF). Rockville, MD: Agency for Healthcare Research and Quality.Murray, L. M., & Laditka, S. B. (2010). Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research. Journal of the American Medical Directors Association, 11(4), 231-238.LaMantia, M. A., Scheunemann, L. P., Viera, A. J., Busby, Whitehead, J., & Hanson, L.C. (2010). Interventions to improve transitional care between nursing homes and hospitals: a systematic review. Journal of the American Geriatrics Society, 58(4), 777-782.
  
  
• Does the measure address a quality challenge? Yes. Results from the Transfer of Health Information pilot test suggest there is substantial variability between PAC settings in whether medication information is shared with the patient and/or caregiver at discharge. Pilot testing data was collected from 30 PAC sites (8 HHA, 9 IRF, 6 LTCH, and 7 SNF) between May and July 2017 during the development of the Transfer of Health Information measure. Overall, pilot test sites submitted 744 admission assessment and 625 discharge assessments during pilot testing. Discharge assessments indicated that medication information was shared patients and/or caregivers 53.6% of the time for HHAs, 86.6% for IRFs, 72.5% for LTCHs, and 85.6% for SNFs. [25]
  
  
• Does the measure contribute to efficient use of measurement resources and/or support alignment of measurement across programs? Yes. This measure addresses the transfer of health information across sites of care, a concept not currently addressed by measures in the set. Additionally, this measure would support an IMPACT Act requirement and would support measurement across PAC and LTC settings.
  
  
• Can the measure can be feasibly reported? Yes. The measure is calculated using OASIS data from for HHA patients. Additionally, pilot testing has shown high rates of inter-rater reliablity and debriefing interviews found that the measure can be feasibily reported.
  
  
• Is the measure applicable to and appropriately specified for the program's intended care setting(s), level(s) of analysis, and population(s)? Yes. Yes, the measure is specified for the home health setting and the facility level of analysis.
  
  
• Measure development status: Field Testing
  
  
• If the measure is in current use, have negative unintended issues to the patient been identified? N/A. This measure has not been implemented yet.
  
  
• If the measure is in current use, have implementation challenges outweighing the benefits of the measure have been identified? N/A. This measure has not been implemented yet.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted.
  
  
• PAC/LTC core competency addressed by the measure: This measure addresses several MAP PAC/LTC core concepts including effective transitions of care, accurate transmission of information, adverse drug events, and patient and family education.
  
  
• IMPACT Act Domain addressed by the measure: The IMPACT Act requires a quality measure under the domain of the transfer of health information and care preferences when an individual transitions between post-acute care settings.
  
  

Rationale for measure provided by HHS
The communication of health information, such as that of a medication list, is critical to ensuring safe and effective patient transitions from one health care setting to another. The focus of this measure is the timely communication of health information, such as medication information at PAC discharge/transfer. Incomplete or missing health information such as medications information increases the likelihood of a patient/resident safety risk, often life-threatening. [1,2,3,4,5] Older adults are particularly vulnerable to adverse health outcomes due to insufficient medication information on the part of health care providers due to their higher likelihood for multiple comorbid chronic conditions, polypharmacy, and complicated transitions between care settings. [6] Upon discharge from a post-acute care setting, older adults may be faced with numerous medication changes, appointments, and follow-up details which are especially difficult for individuals with cognitive or functional impairments and/or challenging social circumstances. PAC patients often have complicated medication regimens and require efficient and effective communication and coordination of care between settings, including detailed transfer of medication information to prevent potentially deadly adverse effects. Inter-institutional communication regarding medication regimens is a key factor to improving care transitions and reducing harm to patients. [8] When care transitions are enhanced through care coordination activities, such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans and prevent medical errors. [9] The transfer of the patient’s discharge medication information to the patient, family, and/or caregiver, in the form of a medication list, is common practice, and supported by discharge planning requirements for participation in Medicare and Medicaid programs. Most PAC EHR systems generate a discharge medication list. However, the content included in the medication lists varies and are not standardized. Other critical medication information may not be included in the medication lists provided to patients at care transitions. Furthermore, these lists may not be written in plain, jargon-free language that the patient understands. A pharmacist study identified multiple opportunities to optimize nursing facility discharge medication lists in order to increase patient safety and potentially reduce readmissions. [10] They noted that nursing facility settings have not made many improvements in discharge medication lists as hospitals have. The pharmacists also identified ideal components of a SNF discharge facility list, providing indications in layperson terms, removing irrelevant information, and maximizing readability. An objective of this measure is to improve and standardize the type of medication list information transferred to patients, and to increase, over time, the secure, timely, electronic transfer of the reconciled medication list electronically (e.g., through patient portals) through PAC EHR systems and using HIT standards. PAC provider adoption of EHRs and participation in health Information exchange can reduce provider burden through the use and reuse of healthcare data, and supports high quality, personalized, and efficient healthcare, care coordination and person-centered care. Further, the interoperability provisions of the 21st Century Cures Act provide a strong framework to enable electronic sharing and interoperable exchange of medication list information. 1. Minto-Pennant, S. (2016). Roadmap to quality: Effective medication reconciliation minimizes errors in a long-term care setting. Journal of the American Medical Directors Association, 17(3), B21-B21. 2. Boockvar, K. S., Blum, S., Kugler, A., Livote, E., Mergenhagen, K. A., Nebeker, J. R., & Yeh, J. (2011). Effect of admission medication reconciliation on adverse drug events from admission medication changes. Archives of Internal Medicine, 171(9), 860-861. 3. Bell, C. M., Brener, S. S., Gunraj, N., Huo, C., Bierman, A. S., Scales, D. C., & Urbach, D. R. (2011). Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA, 306(8), 840-847. 4. Basey, A. J., Krska, J., Kennedy, T. D., & Mackridge, A. J. (2014). Prescribing errors on admission to hospital and their potential impact: a mixed-methods study. BMJ Quality & Safety, 23(1), 17-25. 5. Desai, R., Williams, C. E., Greene, S. B., Pierson, S., & Hansen, R. A. (2011). Medication errors during patient transitions into nursing homes: characteristics and association with patient harm. The American Journal of Geriatric Pharmacotherapy, 9(6), 413-422. 6. Chhabra, P. T., Rattinger, G. B., Dutcher, S. K., Hare, M. E., Parsons, K., L., & Zuckerman, I. H. (2012). Medication reconciliation during the transition to and from long-term care settings: a systematic review. Res Social Adm Pharm 8(1), 60-75. 7. Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271. 8. Mor, V., Intrator, O., Feng, Z., & Grabowski, D. C. (2010). The revolving door of rehospitalization from skilled nursing facilities. Health Affairs, 29(1), 57-64. 9. Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812. 10. Backes, A.C., Cash, P., &Jordan, J. (2016). Optimizing the use of discharge medication lists in nursing facilities. Consult Pharm, 31, 493-499.

Measure Specifications

• NQF Number (if applicable):
  
  
• Description: This measure will estimate the risk-adjusted rate of transitions from hospice care, followed by death within 30 days or acute care use within 7 days. The measure is risk adjusted to “level the playing field” to allow comparison based on patients with similar characteristics between hospices. The goal of this risk-adjusted measure is to identify hospices that have notably higher rates of negative outcomes, including patient death or acute care following live discharges, when compared to their peers.
  
  
• Numerator: Measure Outcome (Unadjusted Numerator): Number of live discharges that are followed by death within 30 days or a hospitalization/emergency room visit/observation stay within 7 days of hospice discharge. Adjusted Numerator: The numerator is a risk-adjusted estimate of hospice stays that would be predicted to have live discharges that are followed by death within 30 days or a hospitalization/emergency room visit/observation stay within 7 days of hospice discharge. This estimate starts with the observed number of live discharges from hospice that are followed by death or acute care, and is risk adjusted for patient characteristics and a statistical estimate of the hospice effect beyond case mix. The hospice effect captures variation in the measure outcome across hospices, accounting for differences in patient composition. The hospice effect helps isolate the differences in measure performance that are due to hospice behavior and characteristics, thereby producing a more accurate assessment of quality of care. The construction of the risk adjusted numerator uses a statistical model estimated on the national data for all included hospice stays. It is applied to the hospice stays included in the measure and includes the estimated effect of each specific hospice. The prediction equation is based on a logistic statistical model with a two-level hierarchical structure. The patient-stays in the model have an indicator of the discharging hospice; the effect of the hospice is measured as a positive or negative shift in the intercept term of the equation. The hospice effects are modeled as belonging to a normal (Gaussian) distribution centered at 0 and are estimated along with the effects of patient characteristics in the model.
  
  
• Denominator: Eligible Stays (Unadjusted Denominator): The eligible stays for this measure are discharged hospice stays among all Medicare FFS patients not excluded for the reasons listed below: 1. Patients not continuously enrolled in Part A Medicare FFS in the 12 months prior to the hospice admission date, during the hospice stay, or at least 7 days following the hospice discharge date. 2. Patients enrolled in Medicare Advantage in the 12 months prior to the hospice admission date, during the hospice stay, or in the 7 days following the hospice discharge date. 3. Patients who are under 18 years old at hospice admission. Adjusted Denominator: The denominator for this measure is computed the same way as the numerator, but the hospice effect is set at the national average. For the eligible stays at each hospice, the measure denominator is the risk adjusted expected number of stays with transitions from hospice that are followed by death within 30 days or a hospitalization/emergency room visit/observation stay within 7 days of hospice discharge. This estimate includes risk adjustment for patient characteristics with the hospice effect removed. The “expected” number of live discharges from hospice that are followed by death or acute care is the predicted number of live discharges from hospice that are followed by death or acute care if the same patients were treated in the “average” hospice.
  
  
• Exclusions: Denominator exclusions: Patients are excluded from the denominator if they meet one or more of the following criteria: 1. Patients not continuously enrolled in Part A Medicare FFS in the 12 months prior to the hospice admission date, during the hospice stay, or at least 7 days following the hospice discharge date. 2. Patients enrolled in Medicare Advantage in the 12 months prior to the hospice admission date, during the hospice stay, or in the 7 days following the hospice discharge date. 3. Patients who are under 18 years old at hospice admission.
  
  
• HHS NQS Priority: Promote Effective Communication & Coordination of Care
  
  
• HHS Data Source: Administrative claims
  
  
• Measure Type: Outcome
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status:
  
  
• Meaningful Measure Area: Admissions and Readmissions to Hospitals
  
  
• Changes to Endorsed Measure Specifications?:
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Conditional support pending NQF endorsement
  
  
• Preliminary analysis summary
  • Contribution to program measure set:Improved care transitions could improve patient experience and reduce avoidable hospital admissions and readmissions.
  • Impact on quality of care for patients:This measure could address a current quality problem and would add an additional outcome measure to the measure set.
  
  
  
• Does the measure address a critical quality objective not currently adequately addressed by the measures in the program set? Yes. Transitions of care are the movement of patients between health care practitioners, settings, and home as their condition and care needs change.[1] Poor transitions of care can lead to adverse events for the patient and potentially result in the need for hospital admission or readmissions. [2] Transitions from hospice care can occur during a patient’s hospice stay or after a patient is discharged alive from hospice. The current measure set does not include any measures that address transitions of care. [1] https://www.jointcommission.org/assets/1/18/Hot_Topics_Transitions_of_Care.pdf[2] Medicare Payment Advisory Commission, Report to the Congress: Reforming the Delivery System, Washington, D.C.: MedPAC, June 2008
  
  
• Is the measure evidence-based and either strongly linked to outcomes or an outcome measure? Yes. This is an outcome measure addressing care transitions. A number of evidence-based models have been developed to outline steps providers can take to improve care transitions. [1][1] https://www.jointcommission.org/assets/1/18/Hot_Topics_Transitions_of_Care.pdf
  
  
• Does the measure address a quality challenge? . Transitions of care at a person’s end of life can be associated with adverse health outcomes, lower patient and family satisfaction, and higher costs. One study found that over 10% of people who died while in hospice care experienced a transition of care, such as admission to a hospital or skilled nursing facility or discharge to home. [1] One potential care transition challenge for the hospice setting is the rate of live discharge. In its March 2018 report Medicare Payment Advisory Commission (MedPAC) found that in 2016 25% of providers had live discharge rates greater than 31% and 10% of providers had rates greater than 53%. MedPAC noted that while some live discharges from hospice are acceptable and expected, higher than normal rates may indicate a quality problem, such as a provider not being able to meet a patient’s or caregiver’s needs. MedPAC supported the idea of a measure of care transitions that could address this concern. [2][1] Wang, S.-Y., et al. (2016). "Transitions Between Healthcare Settings of Hospice Enrollees at the End of Life." Journal of the American Geriatrics Society 64(2): 314-322[2] MedPAC, Report to the Congress: Medicare Payment Policy. March 2018. Available from: http://medpac.gov/docs/default-source/reports/mar18_medpac_entirereport_sec.pdf?sfvrsn=
  
  
• Does the measure contribute to efficient use of measurement resources and/or support alignment of measurement across programs? Yes. The measure is not duplicative of another measure in the program measure set.
  
  
• Can the measure can be feasibly reported? Yes. This measure uses claims data that CMS is already collecting.
  
  
• Is the measure applicable to and appropriately specified for the program's intended care setting(s), level(s) of analysis, and population(s)? Yes. This measure is specified for the hospice care setting and level of analysis.
  
  
• Measure development status: Fully Developed
  
  
• If the measure is in current use, have negative unintended issues to the patient been identified? N/A. This measure has not been implemented.
  
  
• If the measure is in current use, have implementation challenges outweighing the benefits of the measure have been identified? N/A. This measure has not been implemented.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted.
  
  
• IMPACT Act Domain addressed by the measure: The IMPACT Act does not apply to this program
  
  
• Hospice High Priority Area addressed by the measure: No
  
  

Rationale for measure provided by HHS
Transitions of care are broadly defined as patient movement across healthcare settings, including between providers of care and to and from home. [1] The National Academy of Medicine, formerly called the Institute of Medicine, has described care transitions as particularly vulnerable events for patients. If transitions are poorly coordinated and managed, they can cause poor health care outcomes for patients and lead to wasteful resource use. [2] Measuring transitions among hospice patients and assessing outcomes following transitions from hospice care can therefore provide valuable information about hospices’ quality of care. Transitions from hospice care can occur during a patient’s hospice stay or after a patient is discharged alive from hospice. Care transitions at the end of life are burdensome to patients, families, and the health care system at large because they are associated with adverse health outcomes, [3,4] lower patient and family satisfaction, [5] higher health care costs, [6,7] and fragmentation of care delivery. One national study found that over 10% of all hospice decedents experienced a care transition in the last six months of life, including to hospitals, skilled nursing facilities, home health programs, or home without hospice services. [8] Live discharges from hospice care themselves are considered a type of care transition. Though some patients can be discharged alive from hospice because their clinical status improves or stabilizes, live discharges among patients who are still considered terminally ill can be potentially concerning. A live discharge can lead to a patient dying without comprehensive symptom management and psychosocial support for the patient and family. The national rate of live discharge from hospice has declined in recent years, yet concerns about live discharge persist. The Medicare Payment Advisory Commission (MedPAC) found in their 2018 report that in 2016, 25% of providers had live discharge rates greater than 31% and 10% of providers had rates greater than 53%. The 2016 rates of live discharge among hospices in the 75th and 90th percentile are higher than they were in three preceding years. [9,10] MedPAC suggests that although some level of live discharges from hospice may be appropriate, providers with substantially higher rates of live discharge than their peers may have potential quality issues, such as inability to meet patient and caregiver needs. The report also expressed general support for outcome-based quality measures and specific support for a measure that would capture the live discharge rate and burdensome transitions among hospices. Examining subsequent care transitions and other events that occur after a live discharge from hospice can also reveal potential quality of care issues. Most patients express a wish to die at home and outside of the hospital, and patients discharged alive from hospice are more likely to die in a hospital than patients who receive hospice care up until death. [11,12] A national study of live discharges found that among hospice patients who were discharged alive, nearly a quarter were admitted to the hospital, and a third of those hospitalized following live discharge died within a month of hospice discharge. [13] Many patients reenroll in hospice following live discharge, creating greater burden on patients, caregivers, and the healthcare system, regardless of the patient’s outcome. [14] Live discharges from hospice are expected, for example, in cases where survival improves or patient and family preferences change. However, live discharges from hospice followed shortly by acute care utilization or death represent potentially avoidable and undesirable outcomes, and may indicate potential quality concerns. The issue of care transitions is considered critical by both the public and by hospice stakeholders and policy experts. “Avoiding unnecessary hospital/ED admissions and readmissions” was classified as a “Highly Prioritized Measurement Opportunity for Hospice Care” in NQF’s Performance Measurement Coordination Strategy for Hospice and Palliative Care in 2012. [15] References: 1. The Joint Commission. (2012). Transitions of care: The need for a more effective approach to continuing patient care. Retrieved from: https://www.jointcommission.org/assets/1/18/Hot_Topics_Transitions_of_Care.pdf 2. Burton, R. (2012). Improving care transitions (Health Affairs Health Policy Brief). Retrieved from: https://www.rwjf.org/content/dam/farm/reports/issue_briefs/2012/rwjf401314. 3. Aldridge, M. D., Epstein, A. J., Brody, A. A., Lee, E. J., Cherlin, E., & Bradley, E. H. (2016). The impact of reported hospice preferred practices on hospital utilization at the end of life. Medical Care, 54(7), 657-663. 4. Phongtankuel, V., Scherban, B. A., Reid, M. C., Finley, A., Martin, A., Dennis, J., & Adelman, R. D. (2015). Why do home hospice patients return to the hospital? A study of hospice provider perspectives. Journal of Palliative Medicine, 19(1), 51-56. 5. Dolin, R., Hanson, L. C., Rosenblum, S. F., Stearns, S. C., Holmes, G. M., & Silberman, P. (2017). Factors driving live discharge from hospice: provider perspectives. Journal of Pain and Symptom Management, 53(6), 1050-1056. 6. Carlson, M. D., Herrin, J., Du, Q., Epstein, A. J., Cherlin, E., Morrison, R. S., & Bradley, E. H. (2009). Hospice characteristics and the disenrollment of patients with cancer. Health Services Research, 44(6), 2004-2021. 7. MacKenzie, M. A., & Hanlon, A. (2018). Health-care utilization after hospice enrollment in patients with heart failure and cancer. American Journal of Hospice and Palliative Medicine, 35(2), 229-235. 8. Wang, S.-Y., Aldridge, M. D., Gross, C. P., Canavan, M., Cherlin, E., Johnson-Hurzeler, R., & Bradley, E. (2016). Transitions between healthcare settings of hospice enrollees at the end of life. Journal of the American Geriatrics Society, 64(2), 314-322. 9. Medicare Payment Advisory Commission. (2018). Report to the Congress: Medicare payment policy. pp. 339. Retrieved from: http://medpac.gov/docs/default-source/reports/mar18_medpac_entirereport_sec.pdf?sfvrsn=0 10. Medicare Payment Advisory Commission. (2017). Report to the Congress: Medicare payment policy. pp. 322. Retrieved from: http://medpac.gov/docs/default-source/reports/mar17_entirereport.pdf 11. Institute of Medicine. (2015). Dying in America: Improving quality and honoring individual preferences near the end of life. Retrieved from: https://bmjopen.bmj.com/content/bmjopen/4/7/e005196.full.pdf https://www.nap.edu/read/18748/chapter/1. 12. Pathak, E. B., Wieten, S., & Djulbegovic, B. (2014). From hospice to hospital: Short-term follow-up study of hospice patient outcomes in a US acute care hospital surveillance system. BMJ Open. , 4(7). Retrieved from: https://bmjopen.bmj.com/content/bmjopen/4/7/e005196.full.pdf., 13. Teno, J. M., Bowman, J., Plotzke, M., Gozalo, P. L., Christian, T., Miller, S. C., Williams, C., Mor, V. (2015). Characteristics of hospice programs with problematic live discharges. Journal of Pain and Symptom Management, 50(4), 548-552. 14. Aldridge, M. D., Schlesinger, M., Barry, C. L., Morrison, R. S., McCorkle, R., Hurzeler, R., & Bradley, E. H. (2014). National hospice survey results: for-profit status, community engagement, and service. JAMA Internal Medicine, 174(4), 500-506. 15. Measure Applications Partnership. (2012). Performance measurement coordination strategy for hospice and palliative care. pp. 19-20. Retrieved from: https://www.qualityforum.org/Publications/2012/06/Performance_Measurement_Coordination_Strategy_for_Hospice_and_Palliative_Care.aspx

Measure Specifications

• NQF Number (if applicable):
  
  
• Description: The purpose of this measure is to assess for and report on the timely transfer of health information when a patient is discharged from their current setting of care. For this measure, the timely transfer of health information specifically assesses for the transfer of the patient’s current reconciled medication list. This process measure calculates the proportion of patient/resident stays or quality episodes with a discharge/transfer assessment indicating that a current reconciled medication list was provided to the subsequent provider at the time of discharge/transfer.
  
  
• Numerator: The numerator is the number of IRF patient stays with an IRF-PAI discharge/transfer assessment indicating a current reconciled medication list was provided to the subsequent provider at the time of discharge/transfer.
  
  
• Denominator: The denominator for this measure is the total number of IRF Medicare Part A and Medicare Advantage (Part C) patient stays ending in discharge/transfer to the following settings only: a short-term general hospital, a SNF, intermediate care, home under care of an organized home health service organization or hospice, hospice in an institutional facility, a swing bed, another IRF, a LTCH, a Medicaid nursing facility, an inpatient psychiatric facility, or a critical access hospital.
  
  
• Exclusions: Patients who died are not included in this measure
  
  
• HHS NQS Priority: Promote Effective Communication & Coordination of Care
  
  
• HHS Data Source: IRF-PAI
  
  
• Measure Type: Process
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status:
  
  
• Meaningful Measure Area: Transfer of Health Information and Interoperability
  
  
• Changes to Endorsed Measure Specifications?:
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Conditional support pending NQF endorsement
  
  
• Preliminary analysis summary
  • Contribution to program measure set:This measure could help improve the transfer of information about a patient’s medication elements, an important aspect of care transitions. Better care transitions could improve patient outcomes, reduce complications, and lessen the risk of hospital admissions or readmissions.
  • Impact on quality of care for patients:This measure would meet an IMPACT Act requirement, address PAC/LTC core concepts not currently included in the program measure set, and promote alignment across programs.
  
  
  
• Does the measure address a critical quality objective not currently adequately addressed by the measures in the program set? Yes. This measure was developed to meet a requirement of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. While the IPFQR measure set includes a measure assessing if a drug regimen review was conducted, it does not currently address the transfer of information across sites of care. The effective and timely transfer is an important aspect of care coordination. it does not currently address the transfer of information across sites of care. The effective and timely transfer is an important aspect of care coordination. Specifically, this measure addresses the transfer of medication information. Patients in post-acute and long-term settings are more likely to have multiple conditions, requiring multiple medications, and to transition across settings and provider. Improved communication about medication regimens is an important element of care transitions for post-acute and long-term care patients. [1, 2] Improved care transitions could results in fewer complications and readmissions. 1. Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271.2. Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812.
  
  
• Is the measure evidence-based and either strongly linked to outcomes or an outcome measure? Yes. Missing or incomplete information on a patient’s medications has been associated with an increased risk of hospital admission and can be a serious safety risk. [1,2,3,4,5,6] Moreover, improving communication between provider about a patient’s medication regimen has been found to be a key factor to improving care transitions and reducing harm to patients. [7,8] Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between discharging/ transferring and receiving providers, including medication information. [9,10,11] Kwan, J. L., Lo, L., Sampson, M., & Shojania, K. G. (2013). Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Annals of Internal Medicine, 158(5), 397-403.Boockvar, K. S., Blum, S., Kugler, A., Livote, E., Mergenhagen, K. A., Nebeker, J. R., & Yeh, J. (2011). Effect of admission medication reconciliation on adverse drug events from admission medication changes. Archives of Internal Medicine, 171(9), 860-861.Bell, C. M., Brener, S. S., Gunraj, N., Huo, C., Bierman, A. S., Scales, D. C., & Urbach, D. R. (2011). Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA, 306(8), 840-847.Basey, A. J., Krska, J., Kennedy, T. D., & Mackridge, A. J. (2014). Prescribing errors on admission to hospital and their potential impact: a mixed-methods study. BMJ Quality & Safety, 23(1), 17-25.Desai, R., Williams, C. E., Greene, S. B., Pierson, S., & Hansen, R. A. (2011). Medication errors during patient transitions into nursing homes: characteristics and association with patient harm. The American Journal of Geriatric Pharmacotherapy, 9(6), 413-422.Boling, P.A. (2009). Care transitions and home health care. Clinical Geriatric Medicine Feb;25(1):135-48.Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271.Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812.U.S. Agency for Healthcare Research and Quality. (2016). National healthcare quality and disparities report chartbook on care coordination (Pub. No. 16-0015-6-EF). Rockville, MD: Agency for Healthcare Research and Quality.Murray, L. M., & Laditka, S. B. (2010). Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research. Journal of the American Medical Directors Association, 11(4), 231-238.LaMantia, M. A., Scheunemann, L. P., Viera, A. J., Busby, Whitehead, J., & Hanson, L.C. (2010). Interventions to improve transitional care between nursing homes and hospitals: a systematic review. Journal of the American Geriatrics Society, 58(4), 777-782.
  
  
• Does the measure address a quality challenge? Yes. Although the transfer of a patient’s discharge medication information to their next provider and to the patient is a common practice and is part of the discharge planning requirements for participation in Medicare and Medicaid programs, the included information can vary and is not standardized and information is often sent as a as a hard copy, rather than electronically to the recipient’s EHR system or through interoperable exchange. This measure aims to standardize the type of medication information transferred to providers, and, to increase the electronic transfer of medication information.
  
  
• Does the measure contribute to efficient use of measurement resources and/or support alignment of measurement across programs? Yes. This measure addresses the transfer of health information across sites of care, a concept not currently addressed by measures in the set. Additionally, this measure would support an IMPACT Act requirement and would support measurement across PAC and LTC settings.
  
  
• Can the measure can be feasibly reported? Yes. The measure is calculated using data from the IRF-PAI. Additionally, pilot testing has shown high rates of inter-rater reliablity and debriefing interviews found that the measure can be feasibily reported. However, during a recent public comment period on the measure, commenters expressed concern about the ability of PAC providers to transfer the medication list electronically through their EHRs/EMRs, noting concenrs about rate of adoption of EHRs in PAC settings, limited participation in health information exchange (HIE), and how the lack of adoption universally impacts their ability to transfer the information electronically. Commenters also noted the challenges resulting from the lack of standards around medication information exchange. [1]This measure were previously reviewed by MAP and recommended to be refined and resubmitted due to concerns about feasibility and validity. [2] The developer has made several updates to address MAP’s concerns. First, the attribution of the measure has been changed to place accountability on discharging provider rather than the receiving provider. Secondly, the revised version of the measure providers includes a minimum set of patient information that must be transferred rather than the preivous measure which only specified that at least one information type was transferred. 1. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/IMPACT-Medication-Profile-Transferred-Public-Comment-Summary-Report.pdf2. MAP 2017 Considerations for Implementing Measures in Federal Programs:Post-Acute Care and Long-Term Care
  
  
• Is the measure applicable to and appropriately specified for the program's intended care setting(s), level(s) of analysis, and population(s)? Yes. Yes, the measure is specified for the IRF setting and the facility level of analysis.
  
  
• Measure development status: Field Testing
  
  
• If the measure is in current use, have negative unintended issues to the patient been identified? N/A. This measure has not been implemented yet.
  
  
• If the measure is in current use, have implementation challenges outweighing the benefits of the measure have been identified? N/A. This measure has not been implemented yet.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted.
  
  
• PAC/LTC core competency addressed by the measure: This measure addresses several MAP PAC/LTC core concepts including effective transitions of care, accurate transmission of information, and adverse drug events.
  
  
• IMPACT Act Domain addressed by the measure: The IMPACT Act requires a quality measure under the domain of the transfer of health information and care preferences when an individual transitions between post-acute care
  
  

Rationale for measure provided by HHS
The communication of health information, such as that of a medication list, is critical to ensuring safe and effective patient transitions from one health care setting to another. The focus of this measure is the timely communication of health information, such as medication information at PAC discharge/transfer. Health information that is incomplete or missing, such as medication information, increases the likelihood of a patient/resident safety risk, often life-threatening. [1,2,3,4,5,6] Older adults are particularly vulnerable to adverse health outcomes due to insufficient medication information on the part of their health care providers, and their higher likelihood for multiple comorbid chronic conditions, polypharmacy, and complicated transitions between care settings. [7, 8]. Hospitalized patients discharged to SNFs had an average of 13 medications on their hospital discharge list [9], thus SNF and other PAC providers often are in the position of starting complex new medication regimens with little knowledge of the patient or their medication history. Furthermore, medication discrepancies are common, and found to occur in as many as three quarters of SNF admissions and 86 percent of all transitions.[10,11] Older patients being discharged to settings other than their home were more likely to experience a medication discrepancy, increasing their likelihood of experiencing an adverse event. [12] PAC patients often have complicated medication regimens and require efficient and effective communication and coordination of care between settings, including detailed transfer of medication information. Inter-institutional communication regarding medication regimens is a key factor to improving care transitions and reducing harm to patients. [13,14] Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between discharging/ transferring and receiving providers, including medication information. [15,16,17] A comprehensive medication list is an important means of communication this information. The transfer of the patient’s discharge medication information to their next providers and to the patients, in the form of a medication list, is common practice, and supported by discharge planning requirements for participation in Medicare and Medicaid programs. Most PAC EHR systems generate a discharge medication list. However, the content included in the medication lists varies and are not standardized. Other critical medication information may not be included in the medication lists provided at care transitions. Furthermore, these lists are often sent as a hard copy, rather than electronically to the recipient’s EHR system or through interoperable exchange. A pharmacist study identified multiple opportunities to optimize nursing facility discharge medication lists in order to increase patient safety and potentially reduce readmissions. [18]. They noted that nursing facility settings have not made many improvements in discharge medication lists as hospitals have. The pharmacists also identified ideal components of a SNF discharge facility list, including an electronic medication list to minimize human error. An objective of this measure is to improve and standardize the type of medication list information transferred to providers, and, to increase, over time, the secure, timely, electronic transfer of the reconciled medication list using HIT standards. PAC provider adoption of EHRs and participation in health Information exchange can reduce provider burden through the use and reuse of healthcare data, and supports high quality, personalized, and efficient healthcare, care coordination and person-centered care. Further, the interoperability provisions of the 21st Century Cures Act provide a strong framework to enable electronic sharing and interoperable exchange of medication list information. 1. Kwan, J. L., Lo, L., Sampson, M., & Shojania, K. G. (2013). Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Annals of Internal Medicine, 158(5), 397-403. 2. Boockvar, K. S., Blum, S., Kugler, A., Livote, E., Mergenhagen, K. A., Nebeker, J. R., & Yeh, J. (2011). Effect of admission medication reconciliation on adverse drug events from admission medication changes. Archives of Internal Medicine, 171(9), 860-861. 3. Bell, C. M., Brener, S. S., Gunraj, N., Huo, C., Bierman, A. S., Scales, D. C., & Urbach, D. R. (2011). Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA, 306(8), 840-847. 4. Basey, A. J., Krska, J., Kennedy, T. D., & Mackridge, A. J. (2014). Prescribing errors on admission to hospital and their potential impact: a mixed-methods study. BMJ Quality & Safety, 23(1), 17-25. 5. Desai, R., Williams, C. E., Greene, S. B., Pierson, S., & Hansen, R. A. (2011). Medication errors during patient transitions into nursing homes: characteristics and association with patient harm. The American Journal of Geriatric Pharmacotherapy, 9(6), 413-422. 6. Boling, P.A. (2009). Care transitions and home health care. Clinical Geriatric Medicine Feb;25(1):135-48. 7. Chhabra, P. T., Rattinger, G. B., Dutcher, S. K., Hare, M. E., Parsons, K., L., & Zuckerman, I. H. (2012). Medication reconciliation during the transition to and from long-term care settings: a systematic review. Res Social Adm Pharm 8(1), 60-75. 8. Levinson, D. R., & General, I. (2014). Adverse events in skilled nursing facilities: national incidence among Medicare beneficiaries. Washington, DC: U.S. Department of Health and Human Services, Office of the Inspector General. 9. Bell, S. P., Vasilevskis, E. E., Saraf, A. A., Jacobsen, J. M. L., Kripalani, S., Mixon, A. S., ... & Simmons, S. F. (2016). Geriatric syndromes in hospitalized older adults discharged to skilled nursing facilities. Journal of the American Geriatrics Society, 64(4), 715-722. 10. Tjia, J., Bonner, A., Briesacher, B. A., McGee, S., Terrill, E., Miller, K. (2009). Medication discrepancies upon hospital to skilled nursing facility transitions. J Gen Intern Med, 24(5), 630-635. 11. Sinvani, L. D., et al. (2013). Medication reconciliation in continuum of care transitions: a moving target. J Am Med Dir Assoc, 14(9), 668-672 12. Manias, E., Annaikis, N., Considine, J., Weerasuriya, R., & Kusljic, S. (2017). Patient-, medication- and environment-related factors affecting medication discrepancies in older patients. Collegian, 24, 571-577. 13. Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271. 14. Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812. 15. U.S. Agency for Healthcare Research and Quality. (2016). National healthcare quality and disparities report chartbook on care coordination (Pub. No. 16-0015-6-EF). Rockville, MD: Agency for Healthcare Research and Quality. 16. Murray, L. M., & Laditka, S. B. (2010). Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research. Journal of the American Medical Directors Association, 11(4), 231-238. 17. LaMantia, M. A., Scheunemann, L. P., Viera, A. J., Busby-Whitehead, J., & Hanson, L.C. (2010). Interventions to improve transitional care between nursing homes and hospitals: a systematic review. Journal of the American Geriatrics Society, 58(4), 777-782. 18. Backes, A.C., Cash, P., &Jordan, J. (2016). Optimizing the use of discharge medication lists in nursing facilities. Consult Pharm, 31, 493-499.

Measure Specifications

• NQF Number (if applicable):
  
  
• Description: The purpose of this measure is to assess for and report on the timely transfer of health information when a patient is discharged from their current setting of care. For this measure, the timely transfer of health information specifically assesses for the transfer of the patient’s current reconciled medication list. This process measure calculates the proportion of patient/resident stays or quality episodes with a discharge/transfer assessment indicating that a current reconciled medication list was provided to the patient, family, or caregiver at the time of discharge/transfer.
  
  
• Numerator: The numerator is the number of IRF patient stays with an IRF-PAI discharge/transfer assessment indicating a current reconciled medication list was provided to the patient, family and/or caregiver at the time of discharge/transfer.
  
  
• Denominator: The denominator for this measure is the total number of IRF Medicare Part A and Medicare Advantage (Part C) patient stays ending in discharge or transfer to the following settings only: a private home/ apartment (apt.), board/care, assisted living, group home, transitional living or home under care of organized home health service organization or hospice.
  
  
• Exclusions: Patients who died are not included in this measure
  
  
• HHS NQS Priority: Promote Effective Communication & Coordination of Care
  
  
• HHS Data Source: IRF-PAI
  
  
• Measure Type: Process
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status:
  
  
• Meaningful Measure Area: Transfer of Health Information and Interoperability
  
  
• Changes to Endorsed Measure Specifications?:
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Conditional support pending NQF endorsement
  
  
• Preliminary analysis summary
  • Contribution to program measure set:This measure could help improve the transfer of information about a patient’s medication elements, an important aspect of care transitions. Better care transitions could improve patient outcomes, reduce complications, and lessen the risk of hospital admissions or readmissions.
  • Impact on quality of care for patients:This measure would meet an IMPACT Act requirement, address PAC/LTC core concepts not currently included in the program measure set, and promote alignment across programs.
  
  
  
• Does the measure address a critical quality objective not currently adequately addressed by the measures in the program set? Yes. Yes, while the IPFQR measure set includes a measure assessing if a drug regimen review was conducted, it does not currently address the transfer of information across sites of care. The effective and timely transfer is an important aspect of care coordination. Patients in post-acute and long-term settings are more likely to have multiple conditions, requiring multiple medications, and to transition across settings and provider. Improved communication about medication regimens is an important element of care transitions for post-acute and long-term care patients. [1, 2] Improved care transitions could results in fewer complications and readmissions. Specifically, this measure addresses the transfer of medication information to the patient, family and/or caregiver. This measure would address patient and family education and could help patients and caregivers to take a more active role in their care. 1. Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271.2. Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812.
  
  
• Is the measure evidence-based and either strongly linked to outcomes or an outcome measure? Yes. Missing or incomplete information on a patient’s medications has been associated with an increased risk of hospital admission and can be a serious safety risk. [1,2,3,4,5,6] Moreover, improving communication between provider about a patient’s medication regimen has been found to be a key factor to improving care transitions and reducing harm to patients. [7,8] Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between discharging/ transferring and receiving providers, including medication information. [9,10,11] Kwan, J. L., Lo, L., Sampson, M., & Shojania, K. G. (2013). Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Annals of Internal Medicine, 158(5), 397-403.Boockvar, K. S., Blum, S., Kugler, A., Livote, E., Mergenhagen, K. A., Nebeker, J. R., & Yeh, J. (2011). Effect of admission medication reconciliation on adverse drug events from admission medication changes. Archives of Internal Medicine, 171(9), 860-861.Bell, C. M., Brener, S. S., Gunraj, N., Huo, C., Bierman, A. S., Scales, D. C., & Urbach, D. R. (2011). Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA, 306(8), 840-847.Basey, A. J., Krska, J., Kennedy, T. D., & Mackridge, A. J. (2014). Prescribing errors on admission to hospital and their potential impact: a mixed-methods study. BMJ Quality & Safety, 23(1), 17-25.Desai, R., Williams, C. E., Greene, S. B., Pierson, S., & Hansen, R. A. (2011). Medication errors during patient transitions into nursing homes: characteristics and association with patient harm. The American Journal of Geriatric Pharmacotherapy, 9(6), 413-422.Boling, P.A. (2009). Care transitions and home health care. Clinical Geriatric Medicine Feb;25(1):135-48.Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271.Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812.U.S. Agency for Healthcare Research and Quality. (2016). National healthcare quality and disparities report chartbook on care coordination (Pub. No. 16-0015-6-EF). Rockville, MD: Agency for Healthcare Research and Quality.Murray, L. M., & Laditka, S. B. (2010). Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research. Journal of the American Medical Directors Association, 11(4), 231-238.LaMantia, M. A., Scheunemann, L. P., Viera, A. J., Busby, Whitehead, J., & Hanson, L.C. (2010). Interventions to improve transitional care between nursing homes and hospitals: a systematic review. Journal of the American Geriatrics Society, 58(4), 777-782.
  
  
• Does the measure address a quality challenge? Yes. Results from the Transfer of Health Information pilot test suggest there is substantial variability between PAC settings in whether medication information is shared with the patient and/or caregiver at discharge. Pilot testing data was collected from 30 PAC sites (8 HHA, 9 IRF, 6 LTCH, and 7 SNF) between May and July 2017 during the development of the Transfer of Health Information measure. Overall, pilot test sites submitted 744 admission assessment and 625 discharge assessments during pilot testing. Discharge assessments indicated that medication information was shared patients and/or caregivers 53.6% of the time for HHAs, 86.6% for IRFs, 72.5% for LTCHs, and 85.6% for SNFs. [25]
  
  
• Does the measure contribute to efficient use of measurement resources and/or support alignment of measurement across programs? Yes. This measure addresses the transfer of health information across sites of care, a concept not currently addressed by measures in the set. Additionally, this measure would support an IMPACT Act requirement and would support measurement across PAC and LTC settings.
  
  
• Can the measure can be feasibly reported? Yes. The measure is calculated using data from the IRF-PAI. Additionally, pilot testing has shown high rates of inter-rater reliablity and debriefing interviews found that the measure can be feasibily reported.
  
  
• Is the measure applicable to and appropriately specified for the program's intended care setting(s), level(s) of analysis, and population(s)? Yes. Yes, the measure is specified for the IRF setting and the facility level of analysis.
  
  
• Measure development status: Field Testing
  
  
• If the measure is in current use, have negative unintended issues to the patient been identified? N/A. This measure has not been implemented yet.
  
  
• If the measure is in current use, have implementation challenges outweighing the benefits of the measure have been identified? N/A. This measure has not been implemented yet.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted.
  
  
• PAC/LTC core competency addressed by the measure: This measure addresses several MAP PAC/LTC core concepts including effective transitions of care, accurate transmission of information, adverse drug events, and patient and family education.
  
  
• IMPACT Act Domain addressed by the measure: The IMPACT Act requires a quality measure under the domain of the transfer of health information and care preferences when an individual transitions between post-acute care settings.
  
  

Rationale for measure provided by HHS
The communication of health information, such as that of a reconciled medication list, is critical to ensuring safe and effective patient transitions from one health care setting to another. The focus of this measure is the timely communication of health information, such as medication information at PAC discharge/transfer. Incomplete or missing health information such as medications information increases the likelihood of a patient/resident safety risk, often life-threatening. [1,2,3,4,5] Older adults are particularly vulnerable to adverse health outcomes due to insufficient medication information on the part of health care providers due to their higher likelihood for multiple comorbid chronic conditions, polypharmacy, and complicated transitions between care settings. [6] Upon discharge from a post-acute care setting, older adults may be faced with numerous medication changes, appointments, and follow-up details which are especially difficult for individuals with cognitive or functional impairments and/or challenging social circumstances. PAC patients often have complicated medication regimens and require efficient and effective communication and coordination of care between settings, including detailed transfer of medication information to prevent potentially deadly adverse effects. Inter-institutional communication regarding medication regimens is a key factor to improving care transitions and reducing harm to patients. [8] When care transitions are enhanced through care coordination activities, such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans and prevent medical errors. [9] The transfer of the patient’s discharge medication information to the patient, family, and/or caregiver, in the form of a list, is common practice, and supported by discharge planning requirements for participation in Medicare and Medicaid programs. Most PAC EHR systems generate a discharge medication list. However, the content included in the medication lists varies and are not standardized. Other critical medication information may not be included in the medication lists provided to patients at care transitions. Furthermore, these lists may not be written in plain, jargon-free language that the patient understands. A pharmacist study identified multiple opportunities to optimize nursing facility discharge medication lists in order to increase patient safety and potentially reduce readmissions. [10] They noted that nursing facility settings have not made many improvements in discharge medication lists as hospitals have. The pharmacists also identified ideal components of a SNF discharge facility list, providing indications in layperson terms, removing irrelevant information, and maximizing readability. An objective of this measure is to improve and standardize the type of medication information transferred to patients, and to increase, over time, the secure, timely, electronic transfer of the medication list electronically (e.g., through patient portals) through PAC EHR systems and using HIT standards. PAC provider adoption of EHRs and participation in health Information exchange can reduce provider burden through the use and reuse of healthcare data, and supports high quality, personalized, and efficient healthcare, care coordination and person-centered care. Further, the interoperability provisions of the 21st Century Cures Act provide a strong framework to enable electronic sharing and interoperable exchange of medication information. 1. Minto-Pennant, S. (2016). Roadmap to quality: Effective medication reconciliation minimizes errors in a long-term care setting. Journal of the American Medical Directors Association, 17(3), B21-B21. 2. Boockvar, K. S., Blum, S., Kugler, A., Livote, E., Mergenhagen, K. A., Nebeker, J. R., & Yeh, J. (2011). Effect of admission medication reconciliation on adverse drug events from admission medication changes. Archives of Internal Medicine, 171(9), 860-861. 3. Bell, C. M., Brener, S. S., Gunraj, N., Huo, C., Bierman, A. S., Scales, D. C., & Urbach, D. R. (2011). Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA, 306(8), 840-847. 4. Basey, A. J., Krska, J., Kennedy, T. D., & Mackridge, A. J. (2014). Prescribing errors on admission to hospital and their potential impact: a mixed-methods study. BMJ Quality & Safety, 23(1), 17-25. 5. Desai, R., Williams, C. E., Greene, S. B., Pierson, S., & Hansen, R. A. (2011). Medication errors during patient transitions into nursing homes: characteristics and association with patient harm. The American Journal of Geriatric Pharmacotherapy, 9(6), 413-422. 6. Chhabra, P. T., Rattinger, G. B., Dutcher, S. K., Hare, M. E., Parsons, K., L., & Zuckerman, I. H. (2012). Medication reconciliation during the transition to and from long-term care settings: a systematic review. Res Social Adm Pharm 8(1), 60-75. 7. Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271. 8. Mor, V., Intrator, O., Feng, Z., & Grabowski, D. C. (2010). The revolving door of rehospitalization from skilled nursing facilities. Health Affairs, 29(1), 57-64. 9. Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812. 10. Backes, A.C., Cash, P., &Jordan, J. (2016). Optimizing the use of discharge medication lists in nursing facilities. Consult Pharm, 31, 493-499.

Measure Specifications

• NQF Number (if applicable):
  
  
• Description: The purpose of this measure is to assess for and report on the timely transfer of health information when a patient is discharged from their current setting of care. For this measure, the timely transfer of health information specifically assesses for the transfer of the patient’s current reconciled medication list. This process measure calculates the proportion of patient/resident stays or quality episodes with a discharge/transfer assessment indicating that a current reconciled medication list was provided to the subsequent provider at the time of discharge/transfer.
  
  
• Numerator: The numerator is the number of LTCH patient stays with a LTCH CARE Data Set discharge/transfer assessment indicating a current reconciled medication list was provided to the subsequent provider at the time of discharge/transfer.
  
  
• Denominator: The denominator for this measure is the total number of LTCH patient stays, regardless of payer, ending in discharge/transfer to the following settings only: a short-term general hospital, a SNF, intermediate care, home under care of an organized home health service organization or hospice, hospice in an institutional facility, a swing bed, an IRF, another LTCH, a Medicaid nursing facility, an inpatient psychiatric facility, or a critical access hospital.
  
  
• Exclusions: Patients who died are not included in this measure
  
  
• HHS NQS Priority: Promote Effective Communication & Coordination of Care
  
  
• HHS Data Source: LTCH CARE data set
  
  
• Measure Type: Process
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status:
  
  
• Meaningful Measure Area: Transfer of Health Information and Interoperability
  
  
• Changes to Endorsed Measure Specifications?:
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Conditional support pending NQF endorsement
  
  
• Preliminary analysis summary
  • Contribution to program measure set:This measure could help improve the transfer of information about a patient’s medication elements, an important aspect of care transitions. Better care transitions could improve patient outcomes, reduce complications, and lessen the risk of hospital admissions or readmissions.
  • Impact on quality of care for patients:This measure would meet an IMPACT Act requirement, address PAC/LTC core concepts not currently included in the program measure set, and promote alignment across programs.
  
  
  
• Does the measure address a critical quality objective not currently adequately addressed by the measures in the program set? Yes. This measure was developed to meet a requirement of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. While the LTCHQR measure set includes a measure assessing if a drug regimen review was conducted, it does not currently address the transfer of information across sites of care. The effective and timely transfer is an important aspect of care coordination. it does not currently address the transfer of information across sites of care. The effective and timely transfer is an important aspect of care coordination. Specifically, this measure addresses the transfer of medication information. Patients in post-acute and long-term settings are more likely to have multiple conditions, requiring multiple medications, and to transition across settings and provider. Improved communication about medication regimens is an important element of care transitions for post-acute and long-term care patients. [1, 2] Improved care transitions could results in fewer complications and readmissions. 1. Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271.2. Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812.
  
  
• Is the measure evidence-based and either strongly linked to outcomes or an outcome measure? Yes. Missing or incomplete information on a patient’s medications has been associated with an increased risk of hospital admission and can be a serious safety risk. [1,2,3,4,5,6] Moreover, improving communication between provider about a patient’s medication regimen has been found to be a key factor to improving care transitions and reducing harm to patients. [7,8] Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between discharging/ transferring and receiving providers, including medication information. [9,10,11] Kwan, J. L., Lo, L., Sampson, M., & Shojania, K. G. (2013). Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Annals of Internal Medicine, 158(5), 397-403.Boockvar, K. S., Blum, S., Kugler, A., Livote, E., Mergenhagen, K. A., Nebeker, J. R., & Yeh, J. (2011). Effect of admission medication reconciliation on adverse drug events from admission medication changes. Archives of Internal Medicine, 171(9), 860-861.Bell, C. M., Brener, S. S., Gunraj, N., Huo, C., Bierman, A. S., Scales, D. C., & Urbach, D. R. (2011). Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA, 306(8), 840-847.Basey, A. J., Krska, J., Kennedy, T. D., & Mackridge, A. J. (2014). Prescribing errors on admission to hospital and their potential impact: a mixed-methods study. BMJ Quality & Safety, 23(1), 17-25.Desai, R., Williams, C. E., Greene, S. B., Pierson, S., & Hansen, R. A. (2011). Medication errors during patient transitions into nursing homes: characteristics and association with patient harm. The American Journal of Geriatric Pharmacotherapy, 9(6), 413-422.Boling, P.A. (2009). Care transitions and home health care. Clinical Geriatric Medicine Feb;25(1):135-48.Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271.Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812.U.S. Agency for Healthcare Research and Quality. (2016). National healthcare quality and disparities report chartbook on care coordination (Pub. No. 16-0015-6-EF). Rockville, MD: Agency for Healthcare Research and Quality.Murray, L. M., & Laditka, S. B. (2010). Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research. Journal of the American Medical Directors Association, 11(4), 231-238.LaMantia, M. A., Scheunemann, L. P., Viera, A. J., Busby, Whitehead, J., & Hanson, L.C. (2010). Interventions to improve transitional care between nursing homes and hospitals: a systematic review. Journal of the American Geriatrics Society, 58(4), 777-782.
  
  
• Does the measure address a quality challenge? Yes. Although the transfer of a patient’s discharge medication information to their next provider and to the patient is a common practice and is part of the discharge planning requirements for participation in Medicare and Medicaid programs, the included information can vary and is not standardized and information is often sent as a as a hard copy, rather than electronically to the recipient’s EHR system or through interoperable exchange. This measure aims to standardize the type of medication information transferred to providers, and, to increase the electronic transfer of medication information.
  
  
• Does the measure contribute to efficient use of measurement resources and/or support alignment of measurement across programs? Yes. This measure addresses the transfer of health information across sites of care, a concept not currently addressed by measures in the set. Additionally, this measure would support an IMPACT Act requirement and would support measurement across PAC and LTC settings.
  
  
• Can the measure can be feasibly reported? Yes. The measure is calculated using data from the LTCH Care Tool. Additionally, pilot testing has shown high rates of inter-rater reliablity and debriefing interviews found that the measure can be feasibily reported. However, during a recent public comment period on the measure, commenters expressed concern about the ability of PAC providers to transfer the medication list electronically through their EHRs/EMRs, noting concenrs about rate of adoption of EHRs in PAC settings, limited participation in health information exchange (HIE), and how the lack of adoption universally impacts their ability to transfer the information electronically. Commenters also noted the challenges resulting from the lack of standards around medication information exchange. [1]This measure were previously reviewed by MAP and recommended to be refined and resubmitted due to concerns about feasibility and validity. [2] The developer has made several updates to address MAP’s concerns. First, the attribution of the measure has been changed to place accountability on discharging provider rather than the receiving provider. Secondly, the revised version of the measure providers includes a minimum set of patient information that must be transferred rather than the preivous measure which only specified that at least one information type was transferred. 1. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/IMPACT-Medication-Profile-Transferred-Public-Comment-Summary-Report.pdf2. MAP 2017 Considerations for Implementing Measures in Federal Programs:Post-Acute Care and Long-Term Care
  
  
• Is the measure applicable to and appropriately specified for the program's intended care setting(s), level(s) of analysis, and population(s)? Yes. Yes, the measure is specified for the IRF setting and the facility level of analysis.
  
  
• Measure development status: Field Testing
  
  
• If the measure is in current use, have negative unintended issues to the patient been identified? N/A. This measure has not been implemented yet.
  
  
• If the measure is in current use, have implementation challenges outweighing the benefits of the measure have been identified? N/A. This measure has not been implemented yet.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted.
  
  
• PAC/LTC core competency addressed by the measure: This measure addresses several MAP PAC/LTC core concepts including effective transitions of care, accurate transmission of information, and adverse drug events.
  
  
• IMPACT Act Domain addressed by the measure: The IMPACT Act requires a quality measure under the domain of the transfer of health information and care preferences when an individual transitions between post-acute care
  
  

Rationale for measure provided by HHS
The communication of health information, such as that of a medication list, is critical to ensuring safe and effective patient transitions from one health care setting to another. The focus of this measure is the timely communication of health information, such as medication information at PAC discharge/transfer. Health information that is incomplete or missing, such as medication information, increases the likelihood of a patient/resident safety risk, often life-threatening. [1,2,3,4,5,6] Older adults are particularly vulnerable to adverse health outcomes due to insufficient medication information on the part of their health care providers, and their higher likelihood for multiple comorbid chronic conditions, polypharmacy, and complicated transitions between care settings. [7, 8]. Hospitalized patients discharged to SNFs had an average of 13 medications on their hospital discharge list [9], thus SNF and other PAC providers often are in the position of starting complex new medication regimens with little knowledge of the patient or their medication history. Furthermore, medication discrepancies are common, and found to occur in as many as three quarters of SNF admissions and 86 percent of all transitions.[10,11] Older patients being discharged to settings other than their home were more likely to experience a medication discrepancy, increasing their likelihood of experiencing an adverse event. [12] PAC patients often have complicated medication regimens and require efficient and effective communication and coordination of care between settings, including detailed transfer of medication information. Inter-institutional communication regarding medication regimens is a key factor to improving care transitions and reducing harm to patients. [13,14] Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between discharging/ transferring and receiving providers, including medication information. [15,16,17] A comprehensive medication list is an important means of communication this information. The transfer of the patient’s discharge medication information to their next providers and to the patients, in the form of a medication list, is common practice, and supported by discharge planning requirements for participation in Medicare and Medicaid programs. Most PAC EHR systems generate a discharge medication list. However, the content included in the medication lists varies and are not standardized. Other critical medication information may not be included in the medication lists provided at care transitions. Furthermore, these lists are often sent as a hard copy, rather than electronically to the recipient’s EHR system or through interoperable exchange. A pharmacist study identified multiple opportunities to optimize nursing facility discharge medication lists in order to increase patient safety and potentially reduce readmissions. [18]. They noted that nursing facility settings have not made many improvements in discharge medication lists as hospitals have. The pharmacists also identified ideal components of a SNF discharge facility list, including an electronic medication list to minimize human error. An objective of this measure is to improve and standardize the type of medication list information transferred to providers, and, to increase, over time, the secure, timely, electronic transfer of the reconciled medication list using HIT standards. PAC provider adoption of EHRs and participation in health Information exchange can reduce provider burden through the use and reuse of healthcare data, and supports high quality, personalized, and efficient healthcare, care coordination and person-centered care. Further, the interoperability provisions of the 21st Century Cures Act provide a strong framework to enable electronic sharing and interoperable exchange of medication list information. 1. Kwan, J. L., Lo, L., Sampson, M., & Shojania, K. G. (2013). Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Annals of Internal Medicine, 158(5), 397-403. 2. Boockvar, K. S., Blum, S., Kugler, A., Livote, E., Mergenhagen, K. A., Nebeker, J. R., & Yeh, J. (2011). Effect of admission medication reconciliation on adverse drug events from admission medication changes. Archives of Internal Medicine, 171(9), 860-861. 3. Bell, C. M., Brener, S. S., Gunraj, N., Huo, C., Bierman, A. S., Scales, D. C., & Urbach, D. R. (2011). Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA, 306(8), 840-847. 4. Basey, A. J., Krska, J., Kennedy, T. D., & Mackridge, A. J. (2014). Prescribing errors on admission to hospital and their potential impact: a mixed-methods study. BMJ Quality & Safety, 23(1), 17-25. 5. Desai, R., Williams, C. E., Greene, S. B., Pierson, S., & Hansen, R. A. (2011). Medication errors during patient transitions into nursing homes: characteristics and association with patient harm. The American Journal of Geriatric Pharmacotherapy, 9(6), 413-422. 6. Boling, P.A. (2009). Care transitions and home health care. Clinical Geriatric Medicine Feb;25(1):135-48. 7. Chhabra, P. T., Rattinger, G. B., Dutcher, S. K., Hare, M. E., Parsons, K., L., & Zuckerman, I. H. (2012). Medication reconciliation during the transition to and from long-term care settings: a systematic review. Res Social Adm Pharm 8(1), 60-75. 8. Levinson, D. R., & General, I. (2014). Adverse events in skilled nursing facilities: national incidence among Medicare beneficiaries. Washington, DC: U.S. Department of Health and Human Services, Office of the Inspector General. 9. Bell, S. P., Vasilevskis, E. E., Saraf, A. A., Jacobsen, J. M. L., Kripalani, S., Mixon, A. S., ... & Simmons, S. F. (2016). Geriatric syndromes in hospitalized older adults discharged to skilled nursing facilities. Journal of the American Geriatrics Society, 64(4), 715-722. 10. Tjia, J., Bonner, A., Briesacher, B. A., McGee, S., Terrill, E., Miller, K. (2009). Medication discrepancies upon hospital to skilled nursing facility transitions. J Gen Intern Med, 24(5), 630-635. 11. Sinvani, L. D., et al. (2013). Medication reconciliation in continuum of care transitions: a moving target. J Am Med Dir Assoc, 14(9), 668-672 12. Manias, E., Annaikis, N., Considine, J., Weerasuriya, R., & Kusljic, S. (2017). Patient-, medication- and environment-related factors affecting medication discrepancies in older patients. Collegian, 24, 571-577. 13. Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271. 14. Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812. 15. U.S. Agency for Healthcare Research and Quality. (2016). National healthcare quality and disparities report chartbook on care coordination (Pub. No. 16-0015-6-EF). Rockville, MD: Agency for Healthcare Research and Quality. 16. Murray, L. M., & Laditka, S. B. (2010). Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research. Journal of the American Medical Directors Association, 11(4), 231-238. 17. LaMantia, M. A., Scheunemann, L. P., Viera, A. J., Busby-Whitehead, J., & Hanson, L.C. (2010). Interventions to improve transitional care between nursing homes and hospitals: a systematic review. Journal of the American Geriatrics Society, 58(4), 777-782. 18. Backes, A.C., Cash, P., &Jordan, J. (2016). Optimizing the use of discharge medication lists in nursing facilities. Consult Pharm, 31, 493-499.

Measure Specifications

• NQF Number (if applicable):
  
  
• Description: The purpose of this measure is to assess for and report on the timely transfer of health information when a patient is discharged from their current setting of care. For this measure, the timely transfer of health information specifically assesses for the transfer of the patient’s current reconciled medication list. This process measure calculates the proportion of patient/resident stays or quality episodes with a discharge/transfer assessment indicating that a current reconciled medication list was provided to the patient, family or caregiver at the time of discharge/transfer.
  
  
• Numerator: The numerator is the number of LTCH patient stays with a LTCH CARE Data Set discharge/transfer assessment indicating a current reconciled medication list was provided to the patient, family and/or caregiver at the time of discharge/transfer.
  
  
• Denominator: The denominator for this measure is the total number of LTCH patient stays, regardless of payer, ending in discharge or transfer to the following settings only: a private home/ apartment (apt.), board/care, assisted living, group home, transitional living or home under care of organized home health service organization or hospice.
  
  
• Exclusions: Patients who died are not included in this measure
  
  
• HHS NQS Priority: Promote Effective Communication & Coordination of Care
  
  
• HHS Data Source: LTCH CARE data set
  
  
• Measure Type: Process
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status:
  
  
• Meaningful Measure Area: Transfer of Health Information and Interoperability
  
  
• Changes to Endorsed Measure Specifications?:
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Conditional support pending NQF endorsement
  
  
• Preliminary analysis summary
  • Contribution to program measure set:This measure could help improve the transfer of information about a patient’s medication elements, an important aspect of care transitions. Better care transitions could improve patient outcomes, reduce complications, and lessen the risk of hospital admissions or readmissions.
  • Impact on quality of care for patients:This measure would meet an IMPACT Act requirement, address PAC/LTC core concepts not currently included in the program measure set, and promote alignment across programs.
  
  
  
• Does the measure address a critical quality objective not currently adequately addressed by the measures in the program set? Yes. Yes, while the LTCHQR measure set includes a measure assessing if a drug regimen review was conducted, it does not currently address the transfer of information across sites of care. The effective and timely transfer is an important aspect of care coordination. Patients in post-acute and long-term settings are more likely to have multiple conditions, requiring multiple medications, and to transition across settings and provider. Improved communication about medication regimens is an important element of care transitions for post-acute and long-term care patients. [1, 2] Improved care transitions could results in fewer complications and readmissions. Specifically, this measure addresses the transfer of medication information to the patient, family and/or caregiver. This measure would address patient and family education and could help patients and caregivers to take a more active role in their care. 1. Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271.2. Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812.
  
  
• Is the measure evidence-based and either strongly linked to outcomes or an outcome measure? Yes. Missing or incomplete information on a patient’s medications has been associated with an increased risk of hospital admission and can be a serious safety risk. [1,2,3,4,5,6] Moreover, improving communication between provider about a patient’s medication regimen has been found to be a key factor to improving care transitions and reducing harm to patients. [7,8] Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between discharging/ transferring and receiving providers, including medication information. [9,10,11] Kwan, J. L., Lo, L., Sampson, M., & Shojania, K. G. (2013). Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Annals of Internal Medicine, 158(5), 397-403.Boockvar, K. S., Blum, S., Kugler, A., Livote, E., Mergenhagen, K. A., Nebeker, J. R., & Yeh, J. (2011). Effect of admission medication reconciliation on adverse drug events from admission medication changes. Archives of Internal Medicine, 171(9), 860-861.Bell, C. M., Brener, S. S., Gunraj, N., Huo, C., Bierman, A. S., Scales, D. C., & Urbach, D. R. (2011). Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA, 306(8), 840-847.Basey, A. J., Krska, J., Kennedy, T. D., & Mackridge, A. J. (2014). Prescribing errors on admission to hospital and their potential impact: a mixed-methods study. BMJ Quality & Safety, 23(1), 17-25.Desai, R., Williams, C. E., Greene, S. B., Pierson, S., & Hansen, R. A. (2011). Medication errors during patient transitions into nursing homes: characteristics and association with patient harm. The American Journal of Geriatric Pharmacotherapy, 9(6), 413-422.Boling, P.A. (2009). Care transitions and home health care. Clinical Geriatric Medicine Feb;25(1):135-48.Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271.Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812.U.S. Agency for Healthcare Research and Quality. (2016). National healthcare quality and disparities report chartbook on care coordination (Pub. No. 16-0015-6-EF). Rockville, MD: Agency for Healthcare Research and Quality.Murray, L. M., & Laditka, S. B. (2010). Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research. Journal of the American Medical Directors Association, 11(4), 231-238.LaMantia, M. A., Scheunemann, L. P., Viera, A. J., Busby, Whitehead, J., & Hanson, L.C. (2010). Interventions to improve transitional care between nursing homes and hospitals: a systematic review. Journal of the American Geriatrics Society, 58(4), 777-782.
  
  
• Does the measure address a quality challenge? Yes. Results from the Transfer of Health Information pilot test suggest there is substantial variability between PAC settings in whether medication information is shared with the patient and/or caregiver at discharge. Pilot testing data was collected from 30 PAC sites (8 HHA, 9 IRF, 6 LTCH, and 7 SNF) between May and July 2017 during the development of the Transfer of Health Information measure. Overall, pilot test sites submitted 744 admission assessment and 625 discharge assessments during pilot testing. Discharge assessments indicated that medication information was shared patients and/or caregivers 53.6% of the time for HHAs, 86.6% for IRFs, 72.5% for LTCHs, and 85.6% for SNFs. [25]
  
  
• Does the measure contribute to efficient use of measurement resources and/or support alignment of measurement across programs? Yes. This measure addresses the transfer of health information across sites of care, a concept not currently addressed by measures in the set. Additionally, this measure would support an IMPACT Act requirement and would support measurement across PAC and LTC settings.
  
  
• Can the measure can be feasibly reported? Yes. The measure is calculated using data from the LTCH Care Tool. Additionally, pilot testing has shown high rates of inter-rater reliablity and debriefing interviews found that the measure can be feasibily reported.
  
  
• Is the measure applicable to and appropriately specified for the program's intended care setting(s), level(s) of analysis, and population(s)? Yes. Yes, the measure is specified for the IRF setting and the facility level of analysis.
  
  
• Measure development status: Field Testing
  
  
• If the measure is in current use, have negative unintended issues to the patient been identified? N/A. This measure has not been implemented yet.
  
  
• If the measure is in current use, have implementation challenges outweighing the benefits of the measure have been identified? N/A. This measure has not been implemented yet.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted.
  
  
• PAC/LTC core competency addressed by the measure: This measure addresses several MAP PAC/LTC core concepts including effective transitions of care, accurate transmission of information, adverse drug events, and patient and family education.
  
  
• IMPACT Act Domain addressed by the measure: The IMPACT Act requires a quality measure under the domain of the transfer of health information and care preferences when an individual transitions between post-acute care settings.
  
  

Rationale for measure provided by HHS
The communication of health information, such as that of a reconciled medication list, is critical to ensuring safe and effective patient transitions from one health care setting to another. The focus of this measure is the timely communication of health information, such as medication information at PAC discharge/transfer. Incomplete or missing health information such as medications information increases the likelihood of a patient/resident safety risk, often life-threatening. [1,2,3,4,5] Older adults are particularly vulnerable to adverse health outcomes due to insufficient medication information on the part of health care providers due to their higher likelihood for multiple comorbid chronic conditions, polypharmacy, and complicated transitions between care settings. [6] Upon discharge from a post-acute care setting, older adults may be faced with numerous medication changes, appointments, and follow-up details which are especially difficult for individuals with cognitive or functional impairments and/or challenging social circumstances. PAC patients often have complicated medication regimens and require efficient and effective communication and coordination of care between settings, including detailed transfer of medication information to prevent potentially deadly adverse effects. Inter-institutional communication regarding medication regimens is a key factor to improving care transitions and reducing harm to patients. [8] When care transitions are enhanced through care coordination activities, such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans and prevent medical errors. [9] The transfer of the patient’s discharge medication information to the patient, family, and/or caregiver, in the form of a list, is common practice, and supported by discharge planning requirements for participation in Medicare and Medicaid programs. Most PAC EHR systems generate a discharge medication list. However, the content included in the medication lists varies and are not standardized. Other critical medication information may not be included in the medication lists provided to patients at care transitions. Furthermore, these lists may not be written in plain, jargon-free language that the patient understands. A pharmacist study identified multiple opportunities to optimize nursing facility discharge medication lists in order to increase patient safety and potentially reduce readmissions. [10] They noted that nursing facility settings have not made many improvements in discharge medication lists as hospitals have. The pharmacists also identified ideal components of a SNF discharge facility list, providing indications in layperson terms, removing irrelevant information, and maximizing readability. An objective of this measure is to improve and standardize the type of medication information transferred to patients, and to increase, over time, the secure, timely, electronic transfer of the medication list electronically (e.g., through patient portals) through PAC EHR systems and using HIT standards. PAC provider adoption of EHRs and participation in health Information exchange can reduce provider burden through the use and reuse of healthcare data, and supports high quality, personalized, and efficient healthcare, care coordination and person-centered care. Further, the interoperability provisions of the 21st Century Cures Act provide a strong framework to enable electronic sharing and interoperable exchange of medication information. 1. Minto-Pennant, S. (2016). Roadmap to quality: Effective medication reconciliation minimizes errors in a long-term care setting. Journal of the American Medical Directors Association, 17(3), B21-B21. 2. Boockvar, K. S., Blum, S., Kugler, A., Livote, E., Mergenhagen, K. A., Nebeker, J. R., & Yeh, J. (2011). Effect of admission medication reconciliation on adverse drug events from admission medication changes. Archives of Internal Medicine, 171(9), 860-861. 3. Bell, C. M., Brener, S. S., Gunraj, N., Huo, C., Bierman, A. S., Scales, D. C., & Urbach, D. R. (2011). Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA, 306(8), 840-847. 4. Basey, A. J., Krska, J., Kennedy, T. D., & Mackridge, A. J. (2014). Prescribing errors on admission to hospital and their potential impact: a mixed-methods study. BMJ Quality & Safety, 23(1), 17-25. 5. Desai, R., Williams, C. E., Greene, S. B., Pierson, S., & Hansen, R. A. (2011). Medication errors during patient transitions into nursing homes: characteristics and association with patient harm. The American Journal of Geriatric Pharmacotherapy, 9(6), 413-422. 6. Chhabra, P. T., Rattinger, G. B., Dutcher, S. K., Hare, M. E., Parsons, K., L., & Zuckerman, I. H. (2012). Medication reconciliation during the transition to and from long-term care settings: a systematic review. Res Social Adm Pharm 8(1), 60-75. 7. Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271. 8. Mor, V., Intrator, O., Feng, Z., & Grabowski, D. C. (2010). The revolving door of rehospitalization from skilled nursing facilities. Health Affairs, 29(1), 57-64. 9. Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812. 10. Backes, A.C., Cash, P., &Jordan, J. (2016). Optimizing the use of discharge medication lists in nursing facilities. Consult Pharm, 31, 493-499.

Measure Specifications

• NQF Number (if applicable):
  
  
• Description: The purpose of this measure is to assess for and report on the timely transfer of health information when a patient is discharged from their current setting of care. For this measure, the timely transfer of health information specifically assesses for the transfer of the patient’s current reconciled medication list. This process measure calculates the proportion of patient/resident stays or quality episodes with a discharge/transfer assessment indicating that a current reconciled medication list was provided to the subsequent provider at the time of discharge/transfer.
  
  
• Numerator: The numerator is the number of SNF resident stays with an MDS discharge/transfer assessment indicating a current reconciled medication list was provided to the subsequent provider at the time of discharge/transfer.
  
  
• Denominator: The denominator for this measure is the total number of SNF Medicare Part A covered resident stays ending in discharge/transfer to the following settings only: a short-term general hospital, another SNF, intermediate care, home under care of an organized home health service organization or hospice, hospice in an institutional facility, a swing bed, an IRF, a LTCH, a Medicaid nursing facility, an inpatient psychiatric facility, or a critical access hospital.
  
  
• Exclusions: Patients/residents who died are not included in this measure
  
  
• HHS NQS Priority: Promote Effective Communication & Coordination of Care
  
  
• HHS Data Source: MDS
  
  
• Measure Type: Process
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status:
  
  
• Meaningful Measure Area: Transfer of Health Information and Interoperability
  
  
• Changes to Endorsed Measure Specifications?:
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Conditional support pending NQF endorsement
  
  
• Preliminary analysis summary
  • Contribution to program measure set:This measure could help improve the transfer of information about a patient’s medication elements, an important aspect of care transitions. Better care transitions could improve patient outcomes, reduce complications, and lessen the risk of hospital admissions or readmissions.
  • Impact on quality of care for patients:This measure would meet an IMPACT Act requirement, address PAC/LTC core concepts not currently included in the program measure set, and promote alignment across programs.
  
  
  
• Does the measure address a critical quality objective not currently adequately addressed by the measures in the program set? Yes. This measure was developed to meet a requirement of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. While the SNFQRP measure set includes a measure assessing if a drug regimen review was conducted, it does not currently address the transfer of information across sites of care. The effective and timely transfer is an important aspect of care coordination. it does not currently address the transfer of information across sites of care. The effective and timely transfer is an important aspect of care coordination. Specifically, this measure addresses the transfer of medication information. Patients in post-acute and long-term settings are more likely to have multiple conditions, requiring multiple medications, and to transition across settings and provider. Improved communication about medication regimens is an important element of care transitions for post-acute and long-term care patients. [1, 2] Improved care transitions could results in fewer complications and readmissions. 1. Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271.2. Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812.
  
  
• Is the measure evidence-based and either strongly linked to outcomes or an outcome measure? Yes. Missing or incomplete information on a patient’s medications has been associated with an increased risk of hospital admission and can be a serious safety risk. [1,2,3,4,5,6] Moreover, improving communication between provider about a patient’s medication regimen has been found to be a key factor to improving care transitions and reducing harm to patients. [7,8] Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between discharging/ transferring and receiving providers, including medication information. [9,10,11] Kwan, J. L., Lo, L., Sampson, M., & Shojania, K. G. (2013). Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Annals of Internal Medicine, 158(5), 397-403.Boockvar, K. S., Blum, S., Kugler, A., Livote, E., Mergenhagen, K. A., Nebeker, J. R., & Yeh, J. (2011). Effect of admission medication reconciliation on adverse drug events from admission medication changes. Archives of Internal Medicine, 171(9), 860-861.Bell, C. M., Brener, S. S., Gunraj, N., Huo, C., Bierman, A. S., Scales, D. C., & Urbach, D. R. (2011). Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA, 306(8), 840-847.Basey, A. J., Krska, J., Kennedy, T. D., & Mackridge, A. J. (2014). Prescribing errors on admission to hospital and their potential impact: a mixed-methods study. BMJ Quality & Safety, 23(1), 17-25.Desai, R., Williams, C. E., Greene, S. B., Pierson, S., & Hansen, R. A. (2011). Medication errors during patient transitions into nursing homes: characteristics and association with patient harm. The American Journal of Geriatric Pharmacotherapy, 9(6), 413-422.Boling, P.A. (2009). Care transitions and home health care. Clinical Geriatric Medicine Feb;25(1):135-48.Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271.Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812.U.S. Agency for Healthcare Research and Quality. (2016). National healthcare quality and disparities report chartbook on care coordination (Pub. No. 16-0015-6-EF). Rockville, MD: Agency for Healthcare Research and Quality.Murray, L. M., & Laditka, S. B. (2010). Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research. Journal of the American Medical Directors Association, 11(4), 231-238.LaMantia, M. A., Scheunemann, L. P., Viera, A. J., Busby, Whitehead, J., & Hanson, L.C. (2010). Interventions to improve transitional care between nursing homes and hospitals: a systematic review. Journal of the American Geriatrics Society, 58(4), 777-782.
  
  
• Does the measure address a quality challenge? Yes. Although the transfer of a patient’s discharge medication information to their next provider and to the patient is a common practice and is part of the discharge planning requirements for participation in Medicare and Medicaid programs, the included information can vary and is not standardized and information is often sent as a as a hard copy, rather than electronically to the recipient’s EHR system or through interoperable exchange. This measure aims to standardize the type of medication information transferred to providers, and, to increase the electronic transfer of medication information.
  
  
• Does the measure contribute to efficient use of measurement resources and/or support alignment of measurement across programs? Yes. This measure addresses the transfer of health information across sites of care, a concept not currently addressed by measures in the set. Additionally, this measure would support an IMPACT Act requirement and would support measurement across PAC and LTC settings.
  
  
• Can the measure can be feasibly reported? Yes. The measure is calculated using data from the MDS. Additionally, pilot testing has shown high rates of inter-rater reliablity and debriefing interviews found that the measure can be feasibily reported. However, during a recent public comment period on the measure, commenters expressed concern about the ability of PAC providers to transfer the medication list electronically through their EHRs/EMRs, noting concenrs about rate of adoption of EHRs in PAC settings, limited participation in health information exchange (HIE), and how the lack of adoption universally impacts their ability to transfer the information electronically. Commenters also noted the challenges resulting from the lack of standards around medication information exchange. [1]This measure were previously reviewed by MAP and recommended to be refined and resubmitted due to concerns about feasibility and validity. [2] The developer has made several updates to address MAP’s concerns. First, the attribution of the measure has been changed to place accountability on discharging provider rather than the receiving provider. Secondly, the revised version of the measure providers includes a minimum set of patient information that must be transferred rather than the preivous measure which only specified that at least one information type was transferred. 1. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/IMPACT-Medication-Profile-Transferred-Public-Comment-Summary-Report.pdf2. MAP 2017 Considerations for Implementing Measures in Federal Programs:Post-Acute Care and Long-Term Care
  
  
• Is the measure applicable to and appropriately specified for the program's intended care setting(s), level(s) of analysis, and population(s)? Yes. Yes, the measure is specified for the IRF setting and the facility level of analysis.
  
  
• Measure development status: Field Testing
  
  
• If the measure is in current use, have negative unintended issues to the patient been identified? N/A. This measure has not been implemented yet.
  
  
• If the measure is in current use, have implementation challenges outweighing the benefits of the measure have been identified? N/A. This measure has not been implemented yet.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted.
  
  
• PAC/LTC core competency addressed by the measure: This measure addresses several MAP PAC/LTC core concepts including effective transitions of care, accurate transmission of information, and adverse drug events.
  
  
• IMPACT Act Domain addressed by the measure: The IMPACT Act requires a quality measure under the domain of the transfer of health information and care preferences when an individual transitions between post-acute care
  
  

Rationale for measure provided by HHS
The communication of health information, such as that of a medication list, is critical to ensuring safe and effective patient transitions from one health care setting to another. The focus of this measure is the timely communication of health information, such as medication information at PAC discharge/transfer. Health information that is incomplete or missing, such as medication information, increases the likelihood of a patient/resident safety risk, often life-threatening. [1,2,3,4,5,6] Older adults are particularly vulnerable to adverse health outcomes due to insufficient medication information on the part of their health care providers, and their higher likelihood for multiple comorbid chronic conditions, polypharmacy, and complicated transitions between care settings. [7, 8]. Hospitalized patients discharged to SNFs had an average of 13 medications on their hospital discharge list [9], thus SNF and other PAC providers often are in the position of starting complex new medication regimens with little knowledge of the patient or their medication history. Furthermore, medication discrepancies are common, and found to occur in as many as three quarters of SNF admissions and 86 percent of all transitions.[10,11] Older patients being discharged to settings other than their home were more likely to experience a medication discrepancy, increasing their likelihood of experiencing an adverse event. [12] PAC patients often have complicated medication regimens and require efficient and effective communication and coordination of care between settings, including detailed transfer of medication information. Inter-institutional communication regarding medication regimens is a key factor to improving care transitions and reducing harm to patients. [13,14] Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between discharging/ transferring and receiving providers, including medication information. [15,16,17] A comprehensive medication list is an important means of communication this information. The transfer of the patient’s discharge medication information to their next providers and to the patients, in the form of a medication list, is common practice, and supported by discharge planning requirements for participation in Medicare and Medicaid programs. Most PAC EHR systems generate a discharge medication list. However, the content included in the medication lists varies and are not standardized. Other critical medication information may not be included in the medication lists provided at care transitions. Furthermore, these lists are often sent as a hard copy, rather than electronically to the recipient’s EHR system or through interoperable exchange. A pharmacist study identified multiple opportunities to optimize nursing facility discharge medication lists in order to increase patient safety and potentially reduce readmissions. [18]. They noted that nursing facility settings have not made many improvements in discharge medication lists as hospitals have. The pharmacists also identified ideal components of a SNF discharge facility list, including an electronic medication list to minimize human error. An objective of this measure is to improve and standardize the type of medication list information transferred to providers, and, to increase, over time, the secure, timely, electronic transfer of the reconciled medication list using HIT standards. PAC provider adoption of EHRs and participation in health Information exchange can reduce provider burden through the use and reuse of healthcare data, and supports high quality, personalized, and efficient healthcare, care coordination and person-centered care. Further, the interoperability provisions of the 21st Century Cures Act provide a strong framework to enable electronic sharing and interoperable exchange of medication list information. 1. Kwan, J. L., Lo, L., Sampson, M., & Shojania, K. G. (2013). Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Annals of Internal Medicine, 158(5), 397-403. 2. Boockvar, K. S., Blum, S., Kugler, A., Livote, E., Mergenhagen, K. A., Nebeker, J. R., & Yeh, J. (2011). Effect of admission medication reconciliation on adverse drug events from admission medication changes. Archives of Internal Medicine, 171(9), 860-861. 3. Bell, C. M., Brener, S. S., Gunraj, N., Huo, C., Bierman, A. S., Scales, D. C., & Urbach, D. R. (2011). Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA, 306(8), 840-847. 4. Basey, A. J., Krska, J., Kennedy, T. D., & Mackridge, A. J. (2014). Prescribing errors on admission to hospital and their potential impact: a mixed-methods study. BMJ Quality & Safety, 23(1), 17-25. 5. Desai, R., Williams, C. E., Greene, S. B., Pierson, S., & Hansen, R. A. (2011). Medication errors during patient transitions into nursing homes: characteristics and association with patient harm. The American Journal of Geriatric Pharmacotherapy, 9(6), 413-422. 6. Boling, P.A. (2009). Care transitions and home health care. Clinical Geriatric Medicine Feb;25(1):135-48. 7. Chhabra, P. T., Rattinger, G. B., Dutcher, S. K., Hare, M. E., Parsons, K., L., & Zuckerman, I. H. (2012). Medication reconciliation during the transition to and from long-term care settings: a systematic review. Res Social Adm Pharm 8(1), 60-75. 8. Levinson, D. R., & General, I. (2014). Adverse events in skilled nursing facilities: national incidence among Medicare beneficiaries. Washington, DC: U.S. Department of Health and Human Services, Office of the Inspector General. 9. Bell, S. P., Vasilevskis, E. E., Saraf, A. A., Jacobsen, J. M. L., Kripalani, S., Mixon, A. S., ... & Simmons, S. F. (2016). Geriatric syndromes in hospitalized older adults discharged to skilled nursing facilities. Journal of the American Geriatrics Society, 64(4), 715-722. 10. Tjia, J., Bonner, A., Briesacher, B. A., McGee, S., Terrill, E., Miller, K. (2009). Medication discrepancies upon hospital to skilled nursing facility transitions. J Gen Intern Med, 24(5), 630-635. 11. Sinvani, L. D., et al. (2013). Medication reconciliation in continuum of care transitions: a moving target. J Am Med Dir Assoc, 14(9), 668-672 12. Manias, E., Annaikis, N., Considine, J., Weerasuriya, R., & Kusljic, S. (2017). Patient-, medication- and environment-related factors affecting medication discrepancies in older patients. Collegian, 24, 571-577. 13. Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271. 14. Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812. 15. U.S. Agency for Healthcare Research and Quality. (2016). National healthcare quality and disparities report chartbook on care coordination (Pub. No. 16-0015-6-EF). Rockville, MD: Agency for Healthcare Research and Quality. 16. Murray, L. M., & Laditka, S. B. (2010). Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research. Journal of the American Medical Directors Association, 11(4), 231-238. 17. LaMantia, M. A., Scheunemann, L. P., Viera, A. J., Busby-Whitehead, J., & Hanson, L.C. (2010). Interventions to improve transitional care between nursing homes and hospitals: a systematic review. Journal of the American Geriatrics Society, 58(4), 777-782. 18. Backes, A.C., Cash, P., &Jordan, J. (2016). Optimizing the use of discharge medication lists in nursing facilities. Consult Pharm, 31, 493-499.

Measure Specifications

• NQF Number (if applicable):
  
  
• Description: The purpose of this measure is to assess for and report on the timely transfer of health information when a patient is discharged from their current setting of care. For this measure, the timely transfer of health information specifically assesses for the transfer of the patient’s current reconciled medication list. This process measure calculates the proportion of patient/resident stays or quality episodes with a discharge/transfer assessment indicating that a current reconciled medication list was provided to the patient, family or caregiver at the time of discharge/transfer.
  
  
• Numerator: The numerator is the number of SNF resident stays with an MDS discharge/transfer assessment indicating a current reconciled medication list was provided to the patient, family and/or caregiver at the time of discharge/transfer.
  
  
• Denominator: The denominator for this measure is the total number of SNF Medicare Part A covered resident stays ending in discharge or transfer to the following settings only: a private home/ apartment (apt.), board/care, assisted living, group home, transitional living or home under care of organized home health service organization or hospice.
  
  
• Exclusions: Patients/residents who died are not included in this measure
  
  
• HHS NQS Priority: Promote Effective Communication & Coordination of Care
  
  
• HHS Data Source: MDS
  
  
• Measure Type: Process
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• Endorsement Status:
  
  
• Meaningful Measure Area: Transfer of Health Information and Interoperability
  
  
• Changes to Endorsed Measure Specifications?:
• Is the measure specified as an electronic clinical quality measure? No
  
  

Preliminary Analysis of Measure

• Preliminary analysis result: Conditional support pending NQF endorsement
  
  
• Preliminary analysis summary
  • Contribution to program measure set:This measure could help improve the transfer of information about a patient’s medication elements, an important aspect of care transitions. Better care transitions could improve patient outcomes, reduce complications, and lessen the risk of hospital admissions or readmissions.
  • Impact on quality of care for patients:This measure would meet an IMPACT Act requirement, address PAC/LTC core concepts not currently included in the program measure set, and promote alignment across programs.
  
  
  
• Does the measure address a critical quality objective not currently adequately addressed by the measures in the program set? Yes. Yes, while the SNFQRP measure set includes a measure assessing if a drug regimen review was conducted, it does not currently address the transfer of information across sites of care. The effective and timely transfer is an important aspect of care coordination. Patients in post-acute and long-term settings are more likely to have multiple conditions, requiring multiple medications, and to transition across settings and provider. Improved communication about medication regimens is an important element of care transitions for post-acute and long-term care patients. [1, 2] Improved care transitions could results in fewer complications and readmissions. Specifically, this measure addresses the transfer of medication information to the patient, family and/or caregiver. This measure would address patient and family education and could help patients and caregivers to take a more active role in their care. 1. Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271.2. Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812.
  
  
• Is the measure evidence-based and either strongly linked to outcomes or an outcome measure? Yes. Missing or incomplete information on a patient’s medications has been associated with an increased risk of hospital admission and can be a serious safety risk. [1,2,3,4,5,6] Moreover, improving communication between provider about a patient’s medication regimen has been found to be a key factor to improving care transitions and reducing harm to patients. [7,8] Many care transition models, programs, and best practices emphasize the importance of timely communication and information exchange between discharging/ transferring and receiving providers, including medication information. [9,10,11] Kwan, J. L., Lo, L., Sampson, M., & Shojania, K. G. (2013). Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Annals of Internal Medicine, 158(5), 397-403.Boockvar, K. S., Blum, S., Kugler, A., Livote, E., Mergenhagen, K. A., Nebeker, J. R., & Yeh, J. (2011). Effect of admission medication reconciliation on adverse drug events from admission medication changes. Archives of Internal Medicine, 171(9), 860-861.Bell, C. M., Brener, S. S., Gunraj, N., Huo, C., Bierman, A. S., Scales, D. C., & Urbach, D. R. (2011). Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA, 306(8), 840-847.Basey, A. J., Krska, J., Kennedy, T. D., & Mackridge, A. J. (2014). Prescribing errors on admission to hospital and their potential impact: a mixed-methods study. BMJ Quality & Safety, 23(1), 17-25.Desai, R., Williams, C. E., Greene, S. B., Pierson, S., & Hansen, R. A. (2011). Medication errors during patient transitions into nursing homes: characteristics and association with patient harm. The American Journal of Geriatric Pharmacotherapy, 9(6), 413-422.Boling, P.A. (2009). Care transitions and home health care. Clinical Geriatric Medicine Feb;25(1):135-48.Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271.Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812.U.S. Agency for Healthcare Research and Quality. (2016). National healthcare quality and disparities report chartbook on care coordination (Pub. No. 16-0015-6-EF). Rockville, MD: Agency for Healthcare Research and Quality.Murray, L. M., & Laditka, S. B. (2010). Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research. Journal of the American Medical Directors Association, 11(4), 231-238.LaMantia, M. A., Scheunemann, L. P., Viera, A. J., Busby, Whitehead, J., & Hanson, L.C. (2010). Interventions to improve transitional care between nursing homes and hospitals: a systematic review. Journal of the American Geriatrics Society, 58(4), 777-782.
  
  
• Does the measure address a quality challenge? Yes. Results from the Transfer of Health Information pilot test suggest there is substantial variability between PAC settings in whether medication information is shared with the patient and/or caregiver at discharge. Pilot testing data was collected from 30 PAC sites (8 HHA, 9 IRF, 6 LTCH, and 7 SNF) between May and July 2017 during the development of the Transfer of Health Information measure. Overall, pilot test sites submitted 744 admission assessment and 625 discharge assessments during pilot testing. Discharge assessments indicated that medication information was shared patients and/or caregivers 53.6% of the time for HHAs, 86.6% for IRFs, 72.5% for LTCHs, and 85.6% for SNFs. [25]
  
  
• Does the measure contribute to efficient use of measurement resources and/or support alignment of measurement across programs? Yes. This measure addresses the transfer of health information across sites of care, a concept not currently addressed by measures in the set. Additionally, this measure would support an IMPACT Act requirement and would support measurement across PAC and LTC settings.
  
  
• Can the measure can be feasibly reported? Yes. The measure is calculated using data from the MDS. Additionally, pilot testing has shown high rates of inter-rater reliablity and debriefing interviews found that the measure can be feasibily reported.
  
  
• Is the measure applicable to and appropriately specified for the program's intended care setting(s), level(s) of analysis, and population(s)? Yes. Yes, the measure is specified for the IRF setting and the facility level of analysis.
  
  
• Measure development status: Field Testing
  
  
• If the measure is in current use, have negative unintended issues to the patient been identified? N/A. This measure has not been implemented yet.
  
  
• If the measure is in current use, have implementation challenges outweighing the benefits of the measure have been identified? N/A. This measure has not been implemented yet.
  
  
• Is the measure NQF endorsed for the program's setting and level of analysis? Never Submitted.
  
  
• PAC/LTC core competency addressed by the measure: This measure addresses several MAP PAC/LTC core concepts including effective transitions of care, accurate transmission of information, adverse drug events, and patient and family education.
  
  
• IMPACT Act Domain addressed by the measure: The IMPACT Act requires a quality measure under the domain of the transfer of health information and care preferences when an individual transitions between post-acute care settings.
  
  

Rationale for measure provided by HHS
The communication of health information, such as that of a reconciled medication list, is critical to ensuring safe and effective patient transitions from one health care setting to another. The focus of this measure is the timely communication of health information, such as medication information at PAC discharge/transfer. Incomplete or missing health information such as medications information increases the likelihood of a patient/resident safety risk, often life-threatening. [1,2,3,4,5] Older adults are particularly vulnerable to adverse health outcomes due to insufficient medication information on the part of health care providers due to their higher likelihood for multiple comorbid chronic conditions, polypharmacy, and complicated transitions between care settings. [6] Upon discharge from a post-acute care setting, older adults may be faced with numerous medication changes, appointments, and follow-up details which are especially difficult for individuals with cognitive or functional impairments and/or challenging social circumstances. PAC patients often have complicated medication regimens and require efficient and effective communication and coordination of care between settings, including detailed transfer of medication information to prevent potentially deadly adverse effects. Inter-institutional communication regarding medication regimens is a key factor to improving care transitions and reducing harm to patients. [8] When care transitions are enhanced through care coordination activities, such as expedited patient information flow, these activities can reduce duplication of care services and costs of care, resolve conflicting care plans and prevent medical errors. [9] The transfer of the patient’s discharge medication information to the patient, family, and/or caregiver, in the form of a list, is common practice, and supported by discharge planning requirements for participation in Medicare and Medicaid programs. Most PAC EHR systems generate a discharge medication list. However, the content included in the medication lists varies and are not standardized. Other critical medication information may not be included in the medication lists provided to patients at care transitions. Furthermore, these lists may not be written in plain, jargon-free language that the patient understands. A pharmacist study identified multiple opportunities to optimize nursing facility discharge medication lists in order to increase patient safety and potentially reduce readmissions. [10] They noted that nursing facility settings have not made many improvements in discharge medication lists as hospitals have. The pharmacists also identified ideal components of a SNF discharge facility list, providing indications in layperson terms, removing irrelevant information, and maximizing readability. An objective of this measure is to improve and standardize the type of medication information transferred to patients, and to increase, over time, the secure, timely, electronic transfer of the medication list electronically (e.g., through patient portals) through PAC EHR systems and using HIT standards. PAC provider adoption of EHRs and participation in health Information exchange can reduce provider burden through the use and reuse of healthcare data, and supports high quality, personalized, and efficient healthcare, care coordination and person-centered care. Further, the interoperability provisions of the 21st Century Cures Act provide a strong framework to enable electronic sharing and interoperable exchange of medication information. 1. Minto-Pennant, S. (2016). Roadmap to quality: Effective medication reconciliation minimizes errors in a long-term care setting. Journal of the American Medical Directors Association, 17(3), B21-B21. 2. Boockvar, K. S., Blum, S., Kugler, A., Livote, E., Mergenhagen, K. A., Nebeker, J. R., & Yeh, J. (2011). Effect of admission medication reconciliation on adverse drug events from admission medication changes. Archives of Internal Medicine, 171(9), 860-861. 3. Bell, C. M., Brener, S. S., Gunraj, N., Huo, C., Bierman, A. S., Scales, D. C., & Urbach, D. R. (2011). Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA, 306(8), 840-847. 4. Basey, A. J., Krska, J., Kennedy, T. D., & Mackridge, A. J. (2014). Prescribing errors on admission to hospital and their potential impact: a mixed-methods study. BMJ Quality & Safety, 23(1), 17-25. 5. Desai, R., Williams, C. E., Greene, S. B., Pierson, S., & Hansen, R. A. (2011). Medication errors during patient transitions into nursing homes: characteristics and association with patient harm. The American Journal of Geriatric Pharmacotherapy, 9(6), 413-422. 6. Chhabra, P. T., Rattinger, G. B., Dutcher, S. K., Hare, M. E., Parsons, K., L., & Zuckerman, I. H. (2012). Medication reconciliation during the transition to and from long-term care settings: a systematic review. Res Social Adm Pharm 8(1), 60-75. 7. Oakes, S. L., et al. (2011). Transitional care of the long-term care patient. Clin Geriatr Med, 27(2), 259-271. 8. Mor, V., Intrator, O., Feng, Z., & Grabowski, D. C. (2010). The revolving door of rehospitalization from skilled nursing facilities. Health Affairs, 29(1), 57-64. 9. Starmer A. J, Spector N. D., Srivastava R., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med, 37(1), 1803-1812. 10. Backes, A.C., Cash, P., &Jordan, J. (2016). Optimizing the use of discharge medication lists in nursing facilities. Consult Pharm, 31, 493-499.

Program Index

• Inpatient Rehabilitation Facility Quality Reporting Program 
  
  
• Skilled Nursing Facility Quality Reporting Program 
  
  
• Home Health Quality Reporting Program 
  
  
• Long-Term Care Hospital Quality Reporting Program 
  
  
• Hospice Quality Reporting Program 
  
  

Full Program Summaries

Program History and Structure: The Quality Reporting Program (QRP) for Inpatient Rehabilitation Facilities (IRFs) was established in accordance with section 1886(j) of the Social Security Act as amended by section 3004(b) of the Affordable Care Act. The IRF QRP applies to all IRF facilities that receive the IRF PPS (e.g., IRF hospitals, IRF units that are co-located with affiliated acute care facilities, and IRF units affiliated with critical access hospitals [CAHs]). Data sources for IRF QRP measures include Medicare FFS claims, the Center for Disease Control’s National Health Safety Network (CDC NHSN) data submissions, and Inpatient Rehabilitation Facility - Patient Assessment instrument (IRF-PAI) records. The IRF QRP measure development and selection activities take into account established national priorities and input from multi-stakeholder groups. Beginning in FY 2014, IRFs that fail to submit data will be subject to a 2.0 percentage point reduction of the applicable IRF Prospective Payment System (PPS) payment update. Plans for future public reporting of IRF QRP measures are under development. Further, the Improving Medicare Post-Acute Care Transformation of 2014 (IMPACT Act) amends title XVIII (Medicare) of the Social Security Act (the Act) to direct the Secretary of the Department of Health and Human Services (HHS) to require Long-term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs) and Home Health Agencies (HHAs) to report standardized patient assessment data, data on quality measures including resource use measures. The development of standardized data stems from specified assessment domains via the assessment instruments that are used to submit assessment data to CMS by these post-acute care (PAC) providers. The IMPACT Act requires CMS to develop and implement quality measures from five measure domains: functional status, cognitive function, and changes in function and cognitive function; skin integrity and changes in skin integrity; medication reconciliation; incidence of major falls; and the transfer of health information when the individual transitions from the hospital/critical access hospital to PAC provider or home, or from PAC provider to another settings. The IMPACT Act also delineates the implementation of resource use and other measures in at least these following domains: total estimated Medicare spending per beneficiary; discharge to the community; and all condition risk adjusted potentially preventable hospital readmission rates.

High Priority Domains for Future Measure Consideration:

CMS identified the following domain as high-priority for future measure consideration:

Communication/Care Coordination: The communication of health information such as medication profiles is critical to ensuring safe and effective transitions from one health care setting to another. Medication errors, poor communication, and poor coordination between providers, along with the rising incidence of preventable adverse events and hospital readmissions emphasize the importance of the timely transfer of health information and care preferences at transitions.

Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

Program History and Structure: The Improving Medicare Post-Acute Care Transitions Act of 2014 (The IMPACT Act) added Section 1899B to the Social Security Act establishing the Skilled Nursing Facility Quality Reporting Program (SNF QRP). Facilities that submit data under the SNF PPS are required to participate in the SNF QRP, excluding units that are affiliated with critical access hospitals (CAHs). Data sources for SNF QRP measures include Medicare FFS claims as well as Minimum Data Set (MDS) assessment data. The SNF QRP measure development and selection activities take into account established national priorities and input from multi-stakeholder groups. Beginning in FY 2018, providers that fail to submit required quality data to CMS will have their annual updates reduced by 2.0 percentage points. Further, the Improving Medicare Post-Acute Care Transformation of 2014 (IMPACT Act) amends title XVIII (Medicare) of the Social Security Act (the Act) to direct the Secretary of the Department of Health and Human Services (HHS) to require Long-term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs), and Home Health Agencies (HHAs) to report standardized patient assessment data, data on quality measures including resource use measures. The development of standardized data stems from specified assessment domains via the assessment instruments that are used to submit assessment data to CMS by these post-acute care (PAC) providers. The IMPACT Act requires CMS to develop and implement quality measures from five measure domains: functional status, cognitive function, and changes in function and cognitive function; skin integrity and changes in skin integrity; medication reconciliation; incidence of major falls; and the transfer of health information when the individual transitions from the hospital/critical access hospital to PAC provider or home, or from PAC provider to another settings. The IMPACT Act also delineates the implementation of resource use and other measures in at least these following domains: total estimated Medicare spending per beneficiary; discharge to the community; and all condition risk adjusted potentially preventable hospital readmission rates.

High Priority Domains for Future Measure Consideration:

Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

Program History and Structure: The Home Health Quality Reporting Program (HH QRP) was established in accordance with section 1895 (b)(3)(B)(v)(II) of the Social Security Act. Home Health Agencies (HHAs) are required by the Act to submit quality data for use in evaluating quality for Home Health agencies. Section 1895(b) (3)(B)(v)(I) of the Act also requires that HHAs that do not submit quality data to the Secretary be subject to a 2 percent reduction in the annual payment update, effective in calendar year 2007 and every subsequent year. Data sources for the HH QRP include the Outcome and Assessment Information Set (OASIS) and Medicare FFS claims. Data is publically reported on the Home Health Compare website. The HH QRP measure development and selection activities take into account established national priorities and input from multi-stakeholder groups. Further, the Improving Medicare Post-Acute Care Transformation of 2014 (IMPACT Act) amends title XVIII (Medicare) of the Social Security Act (the Act) to direct the Secretary of the Department of Health and Human Services (HHS) to require Long-term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs) and Home Health Agencies (HHAs) to report standardized patient assessment data, data on quality measures including resource use measures. The development of standardized data stems from specified assessment domains via the assessment instruments that are used to submit assessment data to CMS by these post-acute care (PAC) providers. The IMPACT Act requires CMS to develop and implement quality measures from five measure domains: functional status, cognitive function, and changes in function and cognitive function; skin integrity and changes in skin integrity; medication reconciliation; incidence of major falls; and the transfer of health information when the individual transitions from the hospital/critical access hospital to PAC provider or home, or from PAC provider to another settings. The IMPACT Act also delineates the implementation of resource use and other measures in at least these following domains: total estimated Medicare spending per beneficiary; discharge to the community; and all condition risk adjusted potentially preventable hospital readmission rates.

High Priority Domains for Future Measure Consideration:

CMS identified the following domains as high-priority for future measure consideration: