TRANSITIONS OF CARE 2.0
SOCIAL DETERMINANTS OF HEALTH: REVISED CRITERIA
An ACMA collaboration representing the healthcare continuum.
Expertise
National Executive Steering Committee representing 10 practice settings.
Standards
Standards for effective patient’s Transitions of Care.
Implementation
A model framework to facilitate meaningful implementation and measure performance.
Thought Leadership
ACMA included representation from 15 organizations representing 10 practice settings that influence navigation of our healthcare system.
Contributions From:
Transitions of Care Standards
The American Case Management Association established national standards of practice for case management, and now broadens its scope to include the development of Transitions of Care (TOC) Standards.
The phrase Transitions of Care (TOC) describes a process of transferring a patient’s care from one setting or level of care to another, such as from hospital to home or hospital to skilled nursing facility. These transitions are particularly vulnerable points in the healthcare continuum.
The ACMA TOC Standards provide a framework – applicable across all care settings – to implement and evaluate a process to improve care transitions.
Spent on poor transitions of acute care Medicare patients per year.
Standard 1.0
Identify patients at risk for ineffective Transitions of Care
Standard 2.0
Complete a comprehensive Transition assessment
Standard 3.0
Perform, communicate, and implement findings from a Medication Reconciliation
Standard 4.0
Establish a dynamic care plan that addresses all settings across the care continuum
Standard 5.0
Communicate essential care transition information to key stakeholders across the care continuum
Finding Your Way
Implementation
Using these standards can help:
- Patient engagement
- Improve patient experience
- Decrease readmission and Emergency Department utilization
- Medication safety
- Physician satisfaction
- Advance care planning improvements
Transitions of Care
Funding and support for the Transitions of Care initiative is provided by