Care Coordination

Encounter Period

July 1, 20XX - June 30, 20XX

Submission Deadline

September 30, 20XX ; Data submission deadlines on a federal holiday or weekend (Saturday or Sunday) will default to the first business day thereafter in this document where applicable.

Measure Description

Hospital-level, all-cause, risk-standardized readmission measure that focuses on unplanned readmissions 30 days of discharge from an acute hospitalization.

Hybrid measures differ from the claims-only measures in that they merge electronic health record (EHR) data elements with claims-data to calculate the risk-standardized readmission rate. The Hybrid HWR was developed to address complex and critical aspects of care that cannot be derived through claims data alone. The Hybrid HWR uses EHR data including clinical variables and linking elements for each patient:

• Clinical variables (13): Heart Rate, Systolic Blood Pressure, Respiratory Rate, Temperature, Oxygen Saturation, Weight, Hematocrit, White Blood Cell Count, Potassium, Sodium, Bicarbonate, Creatinine, Glucose
• Linking elements (5): CMS Certification Number (CCN), National Provider Identifier (NPI) for MA patients, Medicare beneficiary Identifier (MBI), Inpatient Admission Date, and Discharge date.

It is recommended hospitals only report the FIRST resulted value for EACH core clinical data element collected in the appropriate timeframe, if available. Hospitals may also choose to report ALL values on an encounter during their entire admission; however, only the first resulted values are utilized in the logic for measure calculation.

Measure Rationale

Returning to the hospital for unplanned care disrupts patients’ lives, increases risk of harmful events like healthcare-associated infections, and results in higher costs absorbed by the health care system. High readmission rates of patients with clinically manageable conditions in primary care settings, such as diabetes and bronchial asthma, may identify quality-of-care problems in hospital settings. A measure of readmissions encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions and costs.

Measure Program Alignment

CMS Inpatient Quality Reporting (IQR) program measure.

Improvement Noted As

No actual measure score will be generated by hospitals. Instead, hospitals will report the data values for each of the core clinical data elements for all encounters in the Initial Population. These core clinical data elements will be linked to administrative claims data and used by CMS to calculate results for the Hybrid HWR measure.

Numerator

If a patient has more than one unplanned admission (for any reason) within 30 days after discharge from the index admission, only one is counted as a readmission. The measure looks for a dichotomous yes or no outcome of whether each admitted patient has an unplanned readmission within 30 days. However, if the first readmission after discharge is considered planned, any subsequent unplanned readmission is not counted as an outcome for that index admission because the unplanned readmission could be related to care provided during the intervening planned readmission rather than during the index admission.

Denominator

1. Enrolled in Medicare FFS Part A for the 12 months prior to the date of admission and during the index admission or enrolled in Medicare Advantage;
2. Aged 65 or over;
3. Discharged alive from a non-federal short-term acute care hospital;
4. Not transferred to another acute care facility

Exclusions

The measure excludes index admissions for patients:

1. Admitted to Prospective Payment System (PPS)-exempt cancer hospitals;
2. Without at least 30 days post-discharge enrollment in Medicare FFS;
3. Discharged against medical advice (AMA);
4. Admitted for primary psychiatric diagnoses;
5. Admitted for rehabilitation; or
6. Admitted for medical treatment of cancer

Measure Population (Determines the cases to abstract/submit)

All Medicare FFS and MA hospitalizations for patients aged 65 and older at the start of an inpatient admission, where the length of stay is less than 365 days, and the hospitalization ends during the measurement period.

The initial population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home.

NOTE: All Medicare FFS and MA hospitalizations meeting the above criteria should be included, regardless of whether Medicare FFS/MA is the primary, secondary, or tertiary payer.

Sample Size Requirements

No sampling – report on all information requested in denominator and numerator.

Data Collection Approach

Hybrid – chart extraction of electronic clinical data and administrative claims data.

Data Elements

Core Clinical Data Elements (13)

• Heart Rate
• Systolic Blood Pressure
• Respiratory Rate
• Temperature
• Oxygen Saturation
• Weight
• Hematocrit
• White Blood Cell Count
• Potassium
• Sodium
• Bicarbonate
• Creatinine
• Glucose

For each encounter, please also submit the following Linking Variable:

• CMS Certification Number (CCN)
• National Provider Identifier (NPI) for MA patients
• Medicare Beneficiary Identifier (MBI)
• Inpatient Admission Date
• Discharge Date

Measure Submission and Reporting Channel

Annual-Hospital Quality Reporting (HQR) via patient-level file in QRDA I format

Encounter Period

Calendar Year (January 1, 20XX – December 31, 20XX)

Submission Deadline

May 15, 20XX ; Data submission deadlines on a federal holiday or weekend (Saturday or Sunday) will default to the first business day thereafter in this document where applicable.

Measure Description

The Screening for Social Drivers of Health Measure assesses whether a hospital implements screening for all patients that are 18 years or older at time of admission for food insecurity, housing instability, transportation needs, utility difficulties and interpersonal safety.

To report on this measure, hospitals will provide: (1) The number of patients admitted to the hospital who are 18 years or older at time of admission and who are screened for each of the five HRSNs: Food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety; and (2) the total number of patients who are admitted to the hospital who are 18 years or older on the date they are admitted.

A specific screening tool is not required to be used, but all areas of health- related social needs must be included.

Measure Rationale

The recognition of health disparities and impact of health-related social needs (HRSN) has been heightened in recent years. Economic and social factors, known as drivers of health, are known to affect health outcomes and costs. This measure is derived from the Center for Medicare and Medicaid Innovation’s Accountable Health Communities (AHC) model and has been tested in large populations across states. The intent of this measure is to help ensure hospitals are considering and addressing social needs in the care they provide to their community.

Measure Program Alignment

This is a CMS Hospital Inpatient Quality Reporting (IQR) program measure.

Improvement Noted As

Increase in the rate.

Numerator

The number of patients admitted to an inpatient hospital stay who are 18 years or older on the date of admission and are screened for all of the following five HRSNs: Food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety during their hospital inpatient stay.

Denominator

The number of patients who are admitted to a hospital inpatient stay and who are 18 years or older on the date of admission.

Please note you should not submit zeros in the denominator if no patients meet denominator criteria.

Exclusions

The following patients would be excluded from the denominator:

1. Patients who opt-out of screening.
2. Patients who are themselves unable to complete the screening during their inpatient stay and have no legal guardian or caregiver able to do so on the patient’s behalf during their inpatient stay.
3. Patients who expire during the inpatient stay.

Measure Population (Determines the cases to abstract/submit)

The number of patients who are admitted to a hospital inpatient stay and who are 18 years or older on the date of admission.

Sample Size Requirements

No sampling – report on all information requested in denominator and numerator.

Calculations

The Screening for Social Drivers of Health measure is calculated by dividing the total number of hospital inpatients who are 18 years or older at time of admission and screened for all five health HRSNs by the total number of patients admitted to a hospital inpatient stay and who are 18 years or older at the time of admission.

Data Source

Hospital tracking

Data Available On

The SDOH measures will be publicly reported in the October 2025 public reporting release.

Measure Submission and Reporting Channel

Annual numerator and denominator submission through Hospital Quality Reporting (HQR) System

Encounter Period

Calendar Year (January 1, 20XX – December 31, 20XX)

Submission Deadline

May 15, 20XX ; Data submission deadlines on a federal holiday or weekend (Saturday or Sunday) will default to the first business day thereafter in this document where applicable.

Measure Description

The Screen Positive Rate for Social Drivers of Health Measure provides information on the percent of patients admitted for an inpatient hospital stay who are 18 years or older on the date of admission, were screened for an HRSN (health-related social needs), and who screen positive for one or more of the following five HRSNs: Food insecurity, housing instability, transportation problems, utility difficulties, or interpersonal safety.

Measure Rationale

The recognition of health disparities and impact of health-related social needs (HRSN) has been heightened in recent years. Economic and social factors, known as drivers of health, are known to affect health outcomes and costs. This measure is derived from the Center for Medicare and Medicaid Innovation’s Accountable Health Communities (AHC) model and has been tested in large populations across states. The intent of this measure is to help ensure hospitals are considering and addressing social needs in the care they provide to their community.

Measure Program Alignment

This is a CMS Inpatient Quality Reporting (IQR) program measure.

Improvement Noted As

This measure is not an indication of performance.

Numerator

The number of patients admitted for an inpatient hospital stay who are 18 years or older on the date of admission, who were screened for all five HRSN, and who screen positive for having a need in one or more of the following five HRSNs (calculated separately): Food insecurity, housing instability, transportation needs, utility difficulties, or interpersonal safety.

Denominator

The number of patients admitted for an inpatient hospital stay who are 18 years or older on the date of admission and are screened for all of the following five HRSN (food insecurity, housing instability, transportation needs, utility difficulties and interpersonal safety) during their hospital inpatient stay.

Exclusions

The following patients would be excluded from the denominator:

1. Patients who opt-out of screening.
2. Patients who are themselves unable to complete the screening during their inpatient stay and have no caregiver able to do so on the patient’s behalf during their inpatient stay.
3. Patients who expire during the inpatient stay.

Measure Population (Determines the cases to abstract/submit)

The number of patients admitted for an inpatient hospital stay who are 18 years or older on the date of admission and are screened for all of the following five HSRN (food insecurity, housing instability, transportation needs, utility difficulties and interpersonal safety) during their hospital inpatient stay.

Sample Size Requirements

No sampling – report on all information requested in denominator and numerator.

Calculations

The result of this measure would be calculated as five separate rates . Each rate is derived from the number of patients admitted for an inpatient hospital stay and who are 18 years or older on the date of admission, screened for an HRSN, and who screen positive for each of the five HRSNs— food insecurity, housing instability, transportation needs, utility difficulties, or interpersonal safety—divided by the total number of patients 18 years or older on the date of admission screened for all five HRSNs.

Data Source

Hospital tracking

Data Available On

The SDOH measures will be publicly reported in the October 2025 public reporting release.

Measure Submission and Reporting Channel

Annual numerator and denominator submission through Hospital Quality Reporting (HQR) platform via web-based data form.