Coordinated and Integrated Care

The Discharge to Community-Post Acute Care Measure for Long-Term Care Hospitals (DTC-PAC LTCH) was developed to address the resource use and other measures domain of Discharge to the Community mandated by the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). This outcome measure assesses successful discharge to community from an LTCH, with successful discharge to community including no unplanned rehospitalizations and no death in the 31 days following LTCH discharge.

The Discharge to Community-Post Acute Care Measure for Skilled Nursing Facilities (DTC-PAC SNF) was developed to address the resource use and other measures domain of Discharge to the Community mandated by the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). This outcome measure assesses successful discharge to community from a SNF, with successful discharge to community including no unplanned rehospitalizations and no death in the 31 days following SNF discharge.

The percentage of patients 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for a disease-modifying anti-rheumatic drug (DMARD).

Percentage of home health stays in which patients who had an acute inpatient hospitalization in the 5 days before the start of their home health stay used an emergency department but were not admitted to an acute care hospital during the 30 days following the start of the home health stay.

Percentage of home health stays in which patients used the emergency department but were not admitted to the hospital during the 60 days following the start of the home health stay.

Percentage of all patients transferred from an Emergency Department to another healthcare facility whose medical record documentation indicated that all required information was communicated (sent) to the receiving facility within 60 minutes of transfer For all data elements, the definition of ‘sent’ includes the following:
• Hard copy sent directly with the patient, or 
• Sent via fax or phone within 60 minutes of patient departure, or
• Immediately available via shared Electronic health record (EHR) or Health Information Exchange (HIE) (see definition below)

Percentage of actively enrolled home-based primary care and palliative care patients who received an assessment of their cognitive ability.

Percentage of actively enrolled home-based primary care and palliative care patients who receive an ADL and IADL assessment. 

*Basic ADLs must include but are not limited to: bathing, transferring, toileting, and feeding; Instrumental ADLs (IADL) must include but are not limited to: telephone use and managing own medications

This measure assesses days spent in acute care within 30 days of discharge from an inpatient hospitalization for acute myocardial infarction (AMI) to provide a patient-centered assessment of the post-discharge period. This measure is intended to capture the quality of care transitions provided to discharged patients hospitalized with AMI by collectively measuring a set of adverse acute care outcomes that can occur post-discharge: emergency department (ED) visits, observation stays, and unplanned readmissions at any time during the 30 days post-discharge.

The measure assesses days spent in acute care within 30 days of discharge from an inpatient hospitalization for HF to provide a patient-centered assessment of the post-discharge period. This measure is intended to capture the quality of care transitions provided to discharged patients who had a HF hospitalization by collectively measuring a set of adverse acute care outcomes that can occur post-discharge: emergency department (ED) visits, observation stays, and unplanned readmissions at any time during the 30 days post-discharge.