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Specifications Manual for Joint Commission National Quality Measures (v2015B2)
Home » Patient Referral to Next Level of Care Provider

Release Notes:
Data Element
Version 2015B2

Data Element Name: Patient Referral to Next Level of Care Provider
Collected For: HBIPS-4, HBIPS-5, HBIPS-6, HBIPS-7,
Definition:Documentation in the medical record that the patient was referred to the next level of care provider upon discharge from a hospital-based inpatient psychiatric setting.
Suggested Data Collection Question:Is there documentation in the medical record that the patient was referred to the next level of care provider upon discharge from a hospital-based inpatient psychiatric setting?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

1    The medical record contains documentation that the patient was referred to the next level of care provider upon discharge from a hospital-based inpatient psychiatric setting.

2    The medical record contains documentation of one of the following:

  • the patient or guardian refused the next level of care provider upon discharge from a hospital-based inpatient psychiatric setting
  • the patient or guardian refused to authorize release of information
  • the patient was readmitted to the same facility within 5 days after discharge

3    The medical record contains documentation of one of the following:

  • the patient eloped and was discharged
  • the patient failed to return from leave and was discharged
  • the patient has not yet been discharged from the hospital
  • the patient was discharged from the hospital to another level of care outside of the hospital system from a setting other than a Psychiatric Care Setting
  • the patient's residence is not in the USA, and they are returning to another country after discharge

4    The medical record contains documentation that the patient was not referred to the next level of care provider upon discharge from a hospital-based inpatient psychiatric setting for a reason other than above.

5    The medical record does not contain documentation that the patient was referred to the next level of care provider upon discharge from a hospital-based inpatient psychiatric setting OR unable to determine from medical record documentation.

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.

When a patient checks himself out of a hospital against the advice of his doctor (AMA) this is not the same as an elopement. The patient should still be offered a referral to a next level of care provider. If the patient refuses the referral, select allowable value 2.

When a patient is released from a psychiatric inpatient stay directly after a court hearing, select allowable value 3.

When allowable value 2 or 3 is selected, creation and transmission of a continuing care plan is not required.

A referral to attend support groups, i.e., Alcoholics Anonymous (AA), Narcotics Anonymous (NA), etc. after discharge is not a referral to a next level of care provider. A referral to support groups is a next level of care recommendation.

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:
  • The follow-up prescribing inpatient or outpatient clinician is the clinician who is responsible for managing the patientÂ’s medication regimen after hospital discharge.
  • The prescribing inpatient or outpatient entity is the hospital or clinic that is responsible for managing the patientÂ’s medication regimen after hospital discharge.
  • The treating inpatient or outpatient clinician is the clinician who is responsible for the primary treatment of the patient in the absence of medications.
  • The treating inpatient or outpatient entity is the 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

Patient Referral to Next Level of Care Provider
Specifications Manual for Joint Commission National Quality Measures (v2015B2)
Discharges 10-01-15 (4Q15) through 06-30-16 (2Q16)
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