Get Rewarded for Improving Health Outcomes: Transitions of Care Program

Immediately: Billing and clinical teams must implement new documentation requirements for all hospital discharge follow-ups. (1) Providers must document evidence of inpatient admission notification in the outpatient medical record within three days of discharge (day of discharge through two days after). (2) Providers must receive and integrate discharge information (including responsible practitioner, procedures, diagnosis, medication list, test results, and discharge instructions) in the medical record within three days of discharge. (3) Providers must schedule and complete a follow-up visit with the patient within 30 days of discharge. (4) Billing team must ensure medication reconciliation is documented and completed in the outpatient medical record within 30 days of discharge. Update all encounter forms, EMR templates, and discharge follow-up workflows to include checkboxes and required fields for these four components. Train providers and clinical staff on HEDIS-compliant documentation. Establish a tracking system to monitor compliance with the 30-day visit and medication reconciliation deadlines. Failure to document all four components will result in loss of QIP incentive payment for that patient encounter.