The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool developed by the National Committee for Quality Assurance (NCQA) to measure health system performance on important dimensions of care and service. 

As we continue our commitment to delivering exceptional patient care, we want to emphasize three HEDIS Star measures that are critical to our collective goals: Transitions of Care (TRC), Follow-Up After Emergency Department Visit for People with Multiple High-Risk Chronic Conditions (FMC), and Plan All-Cause Readmission (PCR). 

By focusing on the follow-up and coordination of care received by patients who have had inpatient and emergency care episodes, we can improve not only their health outcomes, satisfaction, and trust, but also reduce overall healthcare costs and prevent avoidable adverse health events. 

Transitions of Care (TRC)

Transitions of Care has four measure components that pertain to the same eligible population which includes individuals age 18+ who had an acute or nonacute inpatient discharge between 1 de janeiro, 2025 and 1 de dezembro, 2025. This population excludes individuals who received hospice services in 2025.

Notification of inpatient admission

Inpatient provider sends a notification that is accessible to the patient’s ongoing care provider (PCP or other) on the day of admission through two days after the admission (three days total) 

What counts: Documentation in the outpatient medical record must include evidence of receipt of the notification date (phone call, email, fax, etc.).

Receipt of discharge information

Inpatient provider sends discharge information to the patient’s ongoing care provider (PCP or other) on the day of discharge through three days after discharge (three days total)

What counts: Discharge information documented in the outpatient medical record including the receipt of discharge information date, which includes ALL of the following: 

• Practitioner responsible for patient during the stay
• Testing results, or no tests pending
• Procedures or treatment provided
• Diagnoses at discharge
• Current medication list
• Instructions for patient care post-discharge

Patient engagement post-discharge

Provider visit (MD, DO, NP, PA, etc.) OR visit by case management (RN/LPN) to the home, telehealth, etc. within 30 days of discharge (31 days total).

Medication reconciliation

Prescribing practitioner, clinical pharmacist, OR registered nurse conducts a medication reconciliation on the date of discharge through 30 days after discharge (31 days total).

Follow-Up After Emergency Department Visit for People with Multiple High-Risk Chronic Conditions (FMC)

Plan All-Cause Readmissions (PCR)

Tips for success:

• Understand how different inpatient facilities share their data with your practice.
• Contact your patient by phone within seven days of notification of discharge to schedule a follow-up visit.
• Perform a medication reconciliation of current and discharge medications within 30 days of discharge.
• Leverage your existing technology to facilitate communication with inpatient providers and other members of your patient’s care team.
• Review discharge plans carefully and deploy tactics to ensure your patients follow through on all aspects of their discharge care plan.
• Use terms such as follow-up hospitalization, admission, discharge, and inpatient stay to document awareness of patient’s hospitalization.
• Document a current medication list within each visit note.
• Include a date for all documentation.