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Release Notes:
Data Element
Version 2013B

Data Element Name: Continuing Care Plan-Principal Discharge Diagnosis
Collected For: HBIPS-6, HBIPS-7,
Definition:Documentation in the medical record of a continuing care plan which includes the principal discharge diagnosis. Such documentation should be transmitted to the next level of care provider by the fifth post-discharge day.
Suggested Data Collection Question:Is there documentation in the medical record of a continuing care plan which includes the principal discharge diagnosis AND was the continuing care plan including the principal discharge diagnosis transmitted to the next level of care provider no later than the fifth post-discharge day?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

1   The medical record contains a continuing care plan which includes the principal discharge diagnosis AND was transmitted to the next level of care provider no later than the fifth post-discharge day.

2   The medical record contains a continuing care plan which includes the principal discharge diagnosis but was not transmitted to the next level of care provider by the fifth post-discharge day.

3   The medical record does not contain a continuing care plan which includes the principal discharge diagnosis or unable to determine from medical record documentation.
PROGRAMMER NOTE:
In order to identify the specific continuing care plan components that are missing, the internal variables (discharge counter and missing flag) must be stored so calculations of rates for each discharge component can be performed.

Notes for Abstraction:If the patient was in an acute-care hospital and had multiple admissions to the psychiatric unit during his or her hospitalization, this information should be abstracted only once at the time of discharge from the hospital or at the time of final discharge from the psychiatric unit.

If the hospital has an electronic medical record (EMR) and the next level of care provider has access to the complete hospital EMR, select allowable value 1. The EMR should contain documentation that the next level of care provider has access to the EMR.

A continuing care plan may consist of one document or several documents which could be considered a continuing care “packet”. The hospital must be able to identify which document(s) make up the continuing care plan and the hospital must identify what specific documents are transmitted to the next level of care provider within the required timeframe.

The first post-discharge day is defined as the day after discharge.

Methods for transmitting the post-discharge continuing care plan include, but are not limited to: U.S. mail, email, fax, EMR access, doctor's mailbox, ambulance transport personnel. Giving a copy of the continuing care plan to the patient does not comprise transmission.

Suggested Data Sources:

  • Aftercare discharge plan
  • Continuing care plan
  • Discharge plan
  • Final discharge summary
  • Interim discharge summary
  • Medication reconciliation form
  • Physician discharge orders
  • Physician progress notes
  • Referral form

Additional Notes: The next level of care providers include the follow-up prescribing inpatient or outpatient clinician, prescribing inpatient or outpatient entity, the treating inpatient or outpatient clinician or the treating inpatient or outpatient entity as described below. If the patient has referrals to more than one clinician or entity for follow up, the prescribing clinician or entity is considered to be the primary next level of care provider. The order of precedence for transmission of the continuing care plan is listed below.
  • The follow-up prescribing inpatient or outpatient clinician or entity is the clinician, hospital or clinic that is responsible for managing the patient’s medication regime after hospital discharge.
  • The treating inpatient or outpatient clinician or entity is the clinician, hospital or clinic that is responsible for the primary treatment of the patient in the absence of medications.
  • Some examples of inpatient or outpatient clinicians include, but are not limited to: primary care physician, psychiatrist, advanced practice nurse (APN), physician assistant (PA) Master of Social Work (MSW) and psychologist. Titles of qualified psychiatric practitioners vary from state to state.
Guidelines for Abstraction:
Inclusion Exclusion
  • None
  • None

Continuing Care Plan-Principal Discharge Diagnosis
Specifications Manual for Joint Commission National Quality Measures (v2013B)
Discharges 07-01-13 (3Q13) through 12-31-13 (4Q13)