Implementation Roadmap

The framework outlines the process for implementation of the Transition of Care Standards 

Suggested Implementation Process

✔ Review standards

✔ Complete the self-assessment

✔ Review Transition of Care Consensus Measures

✔ Determine relevant process and/or outcome measures

✔ Convene representation (Ambulatory, ED, home health, skilled nursing, payor, and community/social agencies) from across the care continuum

✔ Identify care transition opportunities

✔ Engage key organizational leaders

✔ Develop plan

✔ Reassess at regular intervals

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

Structure

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

Process

  • Assess organizational care transitions and identify opportunities
  • Partner with representatives across the care continuum
  • Leverage bi-directional communication

Outcomes

  • Improve patient engagement and experience
  • Decrease readmission and unnecessary ED utilization
  • Enhance medication safety/adherence
  • Align resources to support SDOH needs
  • Improve advance care planning compliance

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.