CMS-10432 Transitions Measures Collection Form

Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program
Online Data Entry Tool Content for Web-Based Measure Collection

FY 2019 and Subsequent Years

IPFs should complete the form in a fillable PDF format and submit via email to: [email protected].

C CN Facility Name

Transition Record

Transition Record with Specified Elements Received by Discharged Patients (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care)

N UMERATOR CY 2017

Patients or their caregiver(s) who received a transition record

(and with whom a review of all included information was documented)

at the time of discharge including, at a minimum, all of the following elements:

Inpatient Care

• Reason for inpatient admission, AND

• Major procedures and tests performed during inpatient stay and summary of results, AND

• Principal diagnosis at discharge

Post-Discharge/ Patient Self-Management

• Current medication list, AND

• Studies pending at discharge (e.g., laboratory, radiological), AND

• Patient instructions

Advance Care Plan

• Advance directives or surrogate decision maker documented OR

• Documented reason for not providing advance care plan

Contact Information/Plan for Follow-up Care

• 24-hour/7-day contact information including physician for emergencies related to inpatient stay, AND

• Contact information for obtaining results of studies pending at discharge, AND

• Plan for follow-up care, AND

• Primary physician, other health care professional, or site designated for follow-up care

DENOMINATOR CY 2017

A ll patients, regardless of age, discharged from an inpatient facility

to home/self care or any other site of care

C CN Facility Name

Transition Record

Timely Transmission of Transition Record (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care)

NUMERATOR CY 2017

Patients for whom a transition record was transmitted to

the facility or primary physician or other health care professional

designated for follow-up care within 24 hours of discharge

DENOMINATOR CY 2017

All patients, regardless of age, discharged from an

inpatient facility (e.g., hospital inpatient or observation,

skilled nursing facility, or rehabilitation facility) to home/self care or

any other site of care

PRA DISCLOSURE STATEMENT

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1171. The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850 Expiration date XX/XX/XXXX

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