Apr 18, 2023
MHR Unplanned Transitions

Carefully planning for patients’ transitions between care and receiving settings can avoid unplanned admissions, ED visits, and the need for higher levels of care. NCQA Standards for Care Transitions are explicit for accredited Case Management (CM), Case Management-Long Term Services & Settings (CM-LTSS) organizations, and those with LTSS Distinction. Please note that LTSS Distinction sits on top of Health Plan or MBHO accreditation, and organizations pursuing Interim Accreditation are not eligible for this Distinction.

A documented process, reports on unplanned transitions for members and populations, and providing materials to members, are required.  Through its consultation with organizations, MHR has found that developing criteria for the identification of planned and unplanned transitions, along with creating Quantitative and Qualitative (Q&Q) reports about its populations, can be the most challenging of these standards.

Identifying Populations at Most Risk   

Identifying your most vulnerable and high-risk populations starts with defining your criteria, which may include but cannot be limited to those in complex case management. Data typically used for populations are contained within predictive modeling tools that take in data on demographics, claims (diagnosis and procedure codes, prior admissions, ED visits, etc.), drugs, and health assessments, and possibly from surveys and health management programs.

Ensure that employees working with care transitions are trained in interpreting information from predictive modeling tools.

When analyzing your data, look for trends or conditions such as:

  • high or repeat utilization of the ED
  • repeat admissions or readmissions
  • comorbidities, including behavioral or cognitive issues
  • high frailty scores
  • multiple prescribed drugs or low drug adherence
    • chronic obstructive pulmonary disease
    • heart attack
    • heart failure
    • pneumonia
    • coronary artery bypass graft (CABG)
    • hip and knee replacements

Your organization’s criteria, as described in your process, help target your populations for further analysis and interventions.  

Identifying Barriers to Unplanned Transitions

Potential barriers or points of failure can be many and vary by population.  Conduct a root cause analysis to establish your priorities and interventions. For example:  


  • Did your documented process execute as planned?
  • Was accountability for each step defined by job title/department?
  • Did communication fail among healthcare team members or between the care and receiving settings?
  • Was communication timely to prevent unplanned transitions?
  • Were social determinant(s) of health identified?
  • Were discharge plan(s) executed as designed?
  • Did discrepancies in medication reconciliation or delays in administering cause adverse effects?
  • Were patients monitored between transfers?
  • Were early warning signs or alerts recognized?
  • Are the staff properly trained on NCQA’s Care Transition standards?

Providers and Practitioners:  

  • Are certain providers or practitioners accountable for a high rate of unplanned transitions?
  • Are narrow networks causing limited access to timely care?
  • Did lack of appointment availability or fragmented care contribute to unplanned transitions?


Q&Q analysis is required annually for Renewal Surveys.  Be sure your data on admissions and ED visits are organized to enable analysis by (sub) populations.

For example:

  • Members enrolled in health management programs
  • Members by county, zip code, etc., and by provider or practitioner
  • Members having high ED utilization and high medication non-adherence rates
  • Members admitted to participating and nonparticipating facilities

When to call MHR for assistance?

MHR’s proprietary tools and training programs on LTSS, CM, and Q&Q Analysis help build skills among your team. Call in time to meet requirements for your look-back period.

Call to Action

  • Verify that you are on target to meet your look-back period and annual requirements
  • Schedule training on Q&Q Analysis
  • Follow our LinkedIn Page.




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