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Specifications Manual for Joint Commission National Quality Measures (v2015A)

Release Notes:
Measure Information Form
Version 2015A


Measure Information Form

Measure Set: Hospital Based Inpatient Psychiatric Services (HBIPS)

Set Measure ID: HBIPS-6

Performance Measure Name: Post discharge continuing care plan created

Description: Patients discharged from a hospital-based inpatient psychiatric setting with a continuing care plan created

Rationale: Patients may not be able to fully report to their next level of care health-care provider their course of hospitalization or discharge treatment recommendations. The aftercare instructions given the patient may not be available to the next level of care provider at the patient’s initial intake or follow-up appointment. In order to provide optimum care, next level of care providers need to know details of precipitating events immediately preceding hospital admission, the patient’s treatment course during hospitalization, discharge medications and next level of care recommendations (American Association of Community Psychiatrists [AACP], 2001).

Type of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Psychiatric inpatients for whom the post discharge continuing care plan is created and contains all of the following: reason for hospitalization, principal discharge diagnosis, discharge medications and next level of care recommendations.
Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Denominator Statement: Psychiatric inpatient discharges

Included Populations:
  • Patients referred for next level of care with ICD-9-CM Principal or Other Diagnosis Codes for Mental Disorders as defined in Appendix A, Table 10.01

Excluded Populations:
  • Patients who expired
  • Patients with an unplanned departure resulting in discharge due to elopement
  • Patients or their guardians who refused aftercare
  • Patients or guardians who refused to sign authorization to release information
  • Patients with an unplanned departure resulting in discharge due to failing to return from leave
  • Patients readmitted to the same facility within 5 days after discharge
  • Patient's residence is not in the USA, and they are returning to another country after discharge

Data Elements:

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative/billing data and medical records.

Data Accuracy: Hospitals may wish to implement periodic audits to monitor and ensure data accuracy.

Measure Analysis Suggestions: The data elements for each of the four discharge elements provide an opportunity to assess each component individually. However, completion of all four discharge categories is required for this measure.

Sampling: Yes. For additional information see the Sampling Section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:
  • Adair, C.E., McDougall, G.M., Mitton, C.R. et al (2005). Continuity of care and health outcomes among persons with severe mental illness. Psychiatric Services, 56(9), 1061-1069.
  • American Psychiatric Association (APA). (1995). Practice guideline for psychiatric evaluation of adults. Washington (DC): American Psychiatric Press, Inc; 1995. 28 p. [58 references]
  • American Association of Community Psychiatrists Continuity of Care Guidelines (2001)

Adopted for CMS Inpatient Psychiatric Facility Quality Reporting Program FY 2014

Measure Algorithm:

HBIPS-6_Page1.jpg v9 HBIPS-6_Page2.jpg v4 HBIPS-6_Page3.jpg v6

| Related Topics |

Measure Information Form HBIPS-6
Specifications Manual for Joint Commission National Quality Measures (v2015A)
Discharges 01-01-15 (1Q15) through 09-30-15 (3Q15)