Measure Information Form

Measure Set: Advanced Certification Heart Failure(ACHF)

Set Measure ID: ACHF-03

Performance Measure Name: Care Transition Record Transmitted

Description: A care transition record is transmitted to a next level of care provider within 7 days of discharge containing ALL of the following:

• Reason for hospitalization
• Procedures performed during this hospitalization
• Treatment(s)/Service(s) provided during this hospitalization
• Discharge medications, including dosage and indication for use
• Follow-up treatment and services needed (e.g., post-discharge therapy, oxygen therapy, durable medical equipment)

Rationale: The hand-over of care from one healthcare provider to another should smooth the transition of care from the inpatient to outpatient setting (van Walraven et al., 2002). Communication and information exchange should be completed to allow sufficient time for the receiving provider to treat the patient. The timeliness of communication should be consistent with the urgency of follow-up required (Kripalani et al., 2007). Communication and information exchange between providers may be in the form of a phone call, fax, or other secure vehicle, such as, mutual access to an electronic health record (EHR).

The Joint Commission's 2017 Disease-Specific Care Advanced Certification Heart Failure standards require: The program [to provide] care coordination services across inpatient and outpatient settings. Requirements specific to heart failure care certification include:

• The program identifies an individual to coordinate the care of participants.
• The program provides participants with access to a practitioner 24 hours a day, 7 days a week (access may include use of the telephone and the internet, and referral to urgent care settings).
• The program communicates important information regarding co-occurring conditions and co-morbidities to appropriate practitioner(s) to treat or manage conditions.
  • The program care coordinator(s) is responsible for the communication of relevant information among practitioners and across settings.
  • The program care coordinator(s) is responsible for sharing information among practitioners in a timeframe that meets the participant's needs.
  • The program care coordinator(s) is responsible for confirming practitioner receipt of information and actions taken.

Type of Measure: Process

Improvement Noted As: Increase in the rate

Risk Adjustment: No.

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

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional information see the Population and Sampling Specifications section.

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

Selected References:

1. Bell CM, Schnipper JL, Auerback AD, Kaboli PJ, Wetterneck TB, Gonzales DV, Arora VM, Zhang JX, Meltzer DO; Association of communication between hospital-based physicians and Primary care providers with patient outcomes. J Gen Intern Med. 2008; 24(3):381-386.
2. Bodenheimer T. Coordinating care – a perilous journey through the health care system.NEJM. 2008;358(10): 1064-1071.
3. Kripalani S, Applications/LocalApps.LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care. JAMA. 2007; 297(8):831-841.
4. Ravel AN, Marchiori GE, Arnold JMO. Improving the continuity of care following discharge of patients hospitalized with heart failure: Is the discharge summary adequate? Can J Cardiol. 2003;19(4):365-370.
5. van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186-192.
6. The Joint Commission. The Joint Commission's 2017 Comprehensive Certification Manual for Disease-Specific Care: Advanced Certification in Heart Failure Addendum. Oakbrook Terrace, IL: Author. 2017.

Measure Algorithm: