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