Implementation Roadmap

The model outlines the framework for implementation of the TOC Standards.


Suggested Implementation Process

✔ Review standards

✔ Complete the self- assessment

✔ Review Transition of Care Consensus Measures

✔ Review the Metric Alignment list to evaluate current quality measures that cross walk to the TOC

✔ Determine relevant process and/or outcome measures

✔ Convene care continuum representatives (Ambulatory, ED, home health, skilled nursing
     community/social agencies)

✔ Identify care transition opportunities

✔ Engage key organizational leaders

✔ Develop plan

✔ Reassess

Quality Metrics

All settings must assure that meaningful process, outcome and patient experience metrics are used to evaluate and continuously improve performance.

Evaluation and Implementation


  • Apply standards to support seamless transitions across all settings
  • Standardize practice to guide transitions
  • Align with regulations across care settings
  • Maximize technology/interoperability


  • Assess organizational care transitions, identify gaps
  • Benchmark performance across ACMA membership
  • Partner with PCP, patient, family, community, social organizations
  • Educate and identify enterprise care management opportunities
  • Leverage bi-directional communication


  • Patient engagement
  • Improve patient experience
  • Decrease readmission / ED utilization
  • Medication safety
  • Physician satisfaction
  • Advance care planning improvements

Measurement of Care

There are over 2500 quality measures associated with care transitions, often practice specific (acute care, payer, ambulatory, skilled nursing facility, home health, hospice and other sites of services) which contributes to a silo approach to care transitions.

Aligned measurement is essential to meaningful assessment of gaps and opportunities for efficient care coordination.  The consensus measures presented within this document are intended to guide evaluation efforts of the effectiveness of the implementation of the ACMA TOC Standards.


Overall Measures

2500 quality measures which may impact care transitions

Quality Program:




Essential Measures

95 essential care transition measures

3 Key Quality Programs:



Consensus Measures

9 Consensus Measures

4 Process measures:

HEDIS Care Transition Measures

5 outcome measures:

Patient safety

Patient experience



Readmission reduction measures selected from Key Quality Programs

Transitions of Care

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Sponsored by

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