The Transitions of Care (TRC) measure assesses the percentage of discharges for members age 18 or older who had each of four reported indicators during the measurement year. This measure applies to Medicare members only, but practices should follow the same workflow for all patients.

TRC services should be provided after the patient’s discharge from one of these inpatient hospital settings:

• • Inpatient acute care hospital
  • Inpatient psychiatric hospital
  • Long-term care hospital
  • Skilled nursing facility (SNF)
  • Inpatient rehabilitation facility

TRC components

1. Notification of inpatient admission – Documentation must include evidence of receipt of notification of inpatient admission on the day of admission or the following day.
   WHAT YOU NEED TO DO: The communication from the hospital must be received on the day of admission or the following day. The notification should be scanned into the medical record with the date it was received.
2. Receipt of discharge information – Documentation of receipt of discharge information on the day of discharge or the following day.
   WHAT YOU NEED TO DO: The communication from the hospital must be received on the day of discharge or the following day. The notification should be scanned into the medical record with the date it was received. Be sure the following information is included:
   • The practitioner responsible for the member’s care during the inpatient stay
   • Procedures or treatment provider
   • Diagnoses at discharge
   • Current medication list (including allergies)
   • Testing results, or documentation of pending tests or no tests pending
   • Instructions for patient care
3. Patient engagement after inpatient discharge – Documentation of patient engagement (e.g., office visits, visits to the home, or telehealth) provided within 30 days after discharge. Do not include patient engagement that occurs on the date of discharge.