Transitions of Care (TRC)
The FOUR requirements needed for patients 18 years and older who have been discharged from the hospital.
What is "Notification of Inpatient Admission", "Receipt of Discharge Information", "Patient Engagement" and "Medication Reconciliation Post Discharge"?
Evidence of a discussion with the patient, or designated surrogate, in 2021 with documentation that includes a plan regarding preferences for resuscitation, life-sustaining treatment, and end-of-life care or notation that the patient previously executed an advance care plan (ACP).
What is Advance Care Planning?
The compliant time frame when women 67–85 years of age had either a bone mineral density (BMD) test or prescription for a drug to treat osteoporosis after sustaining a fracture.
What is 6 months?
If the medical record does not indicate the type of test and the number of returned samples is specified, if there are fewer than ____ samples, the member does NOT meet screening criteria.
What is 3?
MRIs, ultrasounds and /or biopsies.
What is an example that do not close the BCS measure?
I can be completed on the date of discharge through 30 days after discharge.
What is medication reconciliation post-discharge?
What is Chest Pain?
Fractures of finger, toe, face and skull
This colorectal screening test is good for 3 years (2019-2021).
What is a FIT-DNA?
The date(s) the mammogram can be completed for gap closure.
What is October 1, 2019-December 31, 2021?
The number of days for the patient to be evaluated by his or her physician after the date of discharge.
What is 30 days?
An assessment that may include a standardized assessment tool, assessment of 5 ADLS, or assessment of 4 iADLS.
What is the Functional Status Assessment?
A _____ for a BMD does not close the opportunity gap.
What is a referral?
Colorectal cancer or total colectomy at any time in the patient’s history through December 31, 2021
What is an optional exclusion?
Bilateral mastectomy or unilateral mastectomy with a bilateral modifier during the member’s history through Dec 31, 2021
What is an optional exclusion?
The two sub measures for TRC that can be closed with notification the 'day of' through 2 days after the event (3 days total).
What is Notification of Inpatient Admission and Receipt of Discharge Information?
Documentation that does not meet criteria for toileting when assessing ADLs.
What is incontinence/continence?
The age range for the OMW measure.
What is 67-85 years of age?
Two types of FOBT tests.
What is Guaiac (gFOBT) and Immunochemical (FIT)?
For gap closure,the age range of women who had a mammogram to screen for breast cancer between 10/01/2019-12/31/2021.
What is 50-74 years of age?
The THREE types of healthcare providers who can perform the medication reconciliation post-discharge.
What is a Prescribing Practitioner, a Clinical Pharmacist and a Registered Nurse.
The FOUR COA requirements needed for adult patients 66 years and older as of December 31, 2021.
What is Advance Care Planning, Functional Status Assessment, Pain Assessment and Medication Review?
1)Patients who had a Bone Mineral Density test during 24 months prior to fracture 2) Patients who had osteoporosis therapy or a prescription to treat osteoporosis during 12 months prior to fracture
What is a required exclusion?
For this test, evidence that the scope advanced beyond the splenic flexure must be present.
What is a colonoscopy?
What is a required exclusion?