STARS Med Rec
What is the main goal of the Medication Reconciliation (MRP) process?
To prevent avoidable hospital readmissions by identifying and resolving medication gaps and care needs.
Within how many business days must the initial discharge call attempt be made after KRS receives notification?
Within 2 business days of KRS discharge notification.
What two opportunities must be selected when a discharged member is reached by phone?
Discharge Planning for CKD/ESRD Individuals Completed
Reconciled Medication List Completed
If the KRS BOT cannot be activated, what alternative pathway should be used?
Kidney Resource Services: Discharge Pathway
What is the primary purpose of the KRS Inpatient and Discharge Call?
To assess member's recent discharge, post-discharge needs, and provide education and resources to prevent readmission
What Documents must be present to complete a STARS medication reconciliation?
A discharge summary in doc 360 or the member must have a copy of their discharge paperwork
How many total discharge call attempts are required, and within what time frame?
Two call attempts within 7 business days of discharge notification.
For SNP members, within how many days of discharge must all transition‑of‑care requirements be completed?
Within 30 days of discharge
What information must be entered in the Plan of Care regarding post‑discharge medications?
New medications or “no new medications” and how discrepancies were addressed or “no discrepancies.”
KRS discharge calls are completed when a member is discharged from what two places?
Within how many days of discharge must the Medication Reconciliation assessment be completed or marked incomplete?
Within 30 days from discharge.
If a member cannot be reached after two discharge call attempts, what follow‑up action must be taken?
A UTRY letter must be sent and best practice is another call cycle attempt within 30 days post discharge date.
What opportunity status should be used when the nurse determines the discharge alert was inaccurate after previously identifying the gap?
No Gap
Who serves as the single point of contact for SNP members during the 30‑day post‑discharge period, and how should it be documented?
Nurse Case Manager (NCM).
Nurse full name (or first name and the Initial of last name) and phone number and extension
After completing the second discharge call attempt, what must be done to the discharge alert?
The discharge alert must be cleared.
What happens to the Medication Reconciliation process if the member is readmitted within 30 days?
The first STARS medication Reconciliation assessment is submitted incomplete and a new assessment is open upon discharge
What activity is used when documenting DC call contacts and call attempts?
Call Attempt – Discharge
Call.Call Contact – Discharge Call.
What opportunity status should be used when the member understands and is compliant with the discharge plan and DC opp is completed within 30 days?
Gap Closed
What must be documented regarding follow‑up appointments after discharge?
Provider name and appointment date, ensuring it is within 7 days of discharge or documenting attempts made.
What two places is the nurse responsible for checking daily for discharge alerts?
BCRT Report
Filter work que to Discharge Alerts
What should the nurse do if medication discrepancies are identified?
NCM should contact member's provider to notify them of discrepancies. Then document the notification of the provider
What activity should be used if the nurse recieves an inappropriate discharge alert?
For example: No new DC or member is inpatient?
Discharge Planning Activity
*don't forget to also document any call activities completed
What opportunity status should be used if nurse case manager is unable to reach member to complete DC opportunity within 30 days?
Exhausted
When documenting DME needs, how should this be recorded if no DME is required?
Document “NO DME.”
What database is used to obtain the discharge summaries?
Doc 360 using the A-number