Discharged to Community (DTC)
Discharged to Community (DTC) is a claims-based quality measure assessing whether home health patients were discharged to the community and remained there safely, without an unplanned hospital admission or death in the 31 days following discharge. The post-acute care version, DTC-PAC, is used in home health public reporting and joined the expanded HHVBP measure set with the CY2025 performance year.
How the measure works
CMS calculates DTC-PAC from Medicare fee-for-service claims, identifying home health stays that ended with discharge to the community and then checking claims for an unplanned inpatient admission or death within 31 days. A discharge only counts as successful if the patient both goes home and stays out of the hospital through that window. The measure is risk-adjusted using patient characteristics from claims history and typically uses two years of data to achieve statistical reliability, which means results move slowly and reflect sustained performance rather than a good quarter.
Why the 31-day tail changes discharge practice
DTC-PAC effectively extends the agency's accountability past the discharge date. An episode that looks clean internally, goals met, patient stable, discharge OASIS completed, still counts against the agency if the patient is admitted three weeks later. That reframes discharge from an endpoint into a transition to be engineered: confirmed follow-up appointments, a reconciled medication list the patient actually understands, caregiver readiness, and connections to community supports. Agencies that discharge based on visit counts or authorization limits rather than demonstrated self-management stability tend to discover the difference in this measure.
DTC in payment and public reporting
DTC-PAC is publicly reported for home health and was added to the expanded Home Health Value-Based Purchasing model beginning with the CY2025 performance year, as part of the claims-based category that carries 40% of the Total Performance Score in the CY2026 measure set. It also gives referral partners a number that captures something star ratings miss: whether the agency's episodes end durably. For hospitals and ACOs managing readmission exposure, a strong DTC result is a direct answer to their core question about a post-acute partner.
What good looks like
- Discharge criteria based on demonstrated self-management, not visit exhaustion
- A follow-up physician appointment scheduled and confirmed before discharge
- Teach-back on medications and red flags documented at the final visits
- A written plan telling the patient whom to call for problems after discharge
- Discharge decisions reviewed in case conference for high-risk patients rather than left to a single clinician
Frequently asked questions
What counts as an unsuccessful discharge under DTC?
A discharge to the community followed by an unplanned inpatient admission or death within 31 days counts against the measure, as do discharges to institutional settings. Planned admissions are handled by the measure's specifications and risk adjustment.
Is Discharged to Community part of HHVBP?
Yes. DTC-PAC was added to the expanded HHVBP measure set beginning with the CY2025 performance year and sits in the claims-based category, which carries 40% of the Total Performance Score under the CY2026 measure set.
How can an agency influence what happens after discharge?
Mostly by engineering the transition before it: confirmed follow-up appointments, medication reconciliation with teach-back, caregiver preparation, and referrals to community services. Some agencies also run post-discharge phone calls for high-risk patients, which is inexpensive relative to the measure and referral value at stake.