An ACMA collaboration representing the healthcare continuum.



National Executive Steering Committee representing 10 practice settings.


Longitudinal Standards for effective patient’s Transitions of Care.


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 poor transitions

Standard 2.0

Complete a comprehensive assessment

Standard 3.0

Perform and communicate a medication reconciliation

Standard 4.0

Establish a dynamic care management plan that addresses all settings throughout the continuum of care

Standard 5.0

Communicate essential care transition information to key stakeholders across the continuum of care

Finding Your Way


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

17200 Chenal Parkway Suite 300 #345
Little Rock, Arkansas 72223

Sponsored by

Funding and support for the Transitions of Care initiative is provided by Pfizer.