HEDIS^® Tip Sheet

Notes

• The rate is reported as an observed count of 30-day readmissions over the expected count of 30-day readmissions (O/E Ratio).
  • An O/E Ratio below one indicates there were fewer 30-Day Readmissions than expected while an O/E Ratio greater than one indicates more 30-day Readmissions occurred than were expected.
• This measure is risk-adjusted and looks at the predicted probability that the patient may have an unplanned acute readmission.
• The denominator is based on discharges.
• The patient may be in the measure more than once.
• Inpatient and observation stays are counted separately when the first stay’s discharge date and the next stay’s admission date are at least two calendar days apart.
• Includes acute discharges from any type of facility (including behavioral healthcare facilities).

Best Practices

• Establish a structured post-discharge process to track, monitor, and follow up with patients after hospitalization.
• Review discharge instructions with patients and caregivers, and ensure follow-up appointments are scheduled before discharge.
• Coordinate and complete all necessary referrals prior to discharge to support continuity of care.
• Utilize Transitional Care Management (TCM) services for recently discharged patients, particularly those with chronic conditions or elevated readmission risk.
• Reserve timely appointment slots for patients transitioning from inpatient care to outpatient follow-up.
• Provide appointment reminders and outreach to encourage attendance at post-discharge visits.
• Connect patients with community-based resources and support services to address social, behavioral, or care coordination needs that may contribute to readmissions.

Exclusions

Admission Exclusions:

• Hospital stays for the following:
  • The admission date is the same as the discharge date.
  • The member died during the stay.
  • A principal diagnosis of pregnancy on the discharge claim.
  • A principal diagnosis of a condition originating in the perinatal period on the discharge claim.
• Outliers:
  • Three or more hospital stays between January 1 and December 1 of the measurement year for Commercial members.
  • Four or more hospital stays between January 1 and December 1 of the measurement year for Medicaid Expansion members.

Readmission Exclusions:  

• Nonacute inpatient stays.
• Exclude acute hospital admissions with any of the following:
  • A principal diagnosis of pregnancy.
  • A principal diagnosis for a condition originating in the perinatal period.
  • A planned hospital for any of the following:
    • Principal diagnosis of maintenance chemotherapy.
    • Principal diagnosis of rehabilitation.
    • An organ transplant.
    • Potentially planned procedure without a principal acute diagnosis.

General Exclusions:

• Members in hospice during the measurement year.