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 Disease-Specific Care Advanced Certification Heart Failure standards require:

That the program includes both inpatient and outpatient services, including transitions.
The provision of care coordination services across inpatient and outpatient settings.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Care transition record 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(s) and service(s) needed

Included Populations: Not applicable
Excluded Populations: None
Data Elements:

Care Transition Record Transmitted

Care Transition Record-Discharge Medications

Care Transition Record-Follow-Up Treatment(s) and Service(s) Needed

Care Transition Record-Procedures Performed During Hospitalization

Care Transition Record-Reason for Hospitalization

Care Transition Record-Treatment(s)/Service(s) Provided

Denominator Statement: All heart failure patients discharged from a hospital inpatient setting to home or home care

Included Populations:

Discharges with ICD-10-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1, and

A discharge to home, home care, or court/law enforcement

Excluded Populations:

Patients who had a left ventricular assistive device (LVAD) or heart transplant procedure during the hospital stay or a past medical history of an LVAD or heart transplant (ICD-10-PCS procedure code for LVAD and heart transplant as defined in Appendix A Table 2.2, and ICD-10 diagnosis codes on Table 2.13)

Patients less than 18 years of age

Patient who have a Length of Stay greater than 120 days

Patients with Comfort Measures Only documented

Patients enrolled in a Clinical Trial

Patients discharged to locations other than home, home care, or law enforcement

Patients who left against medical advice (AMA)

Data Elements:

Admission Date

Birthdate

Clinical Trial

Comfort Measures Only

Discharge Date

Discharge Disposition

ICD-10-CM Principal Diagnosis Code

ICD-10-PCS Other Procedure Codes

ICD-10-PCS Principal Procedure Code

ICD-10-PCS Principal Procedure Date

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:

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.
Bodenheimer T. Coordinating care a perilous journey through the health care system.NEJM. 2008;358(10): 1064-1071.
Kripalani S, 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.
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.
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.
The Joint Commission. The Joint Commission's 2019 Comprehensive Certification Manual for Disease-Specific Care: Advanced Certification in Heart Failure Addendum. Oakbrook Terrace, IL: Author. 2019.

Measure Algorithm:

Specifications Manual for Joint Commission National Quality Measures (v2023B)
Discharges 07-01-23 (3Q23) through 12-31-23 (4Q23)

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