Self Assessment
ACMA Transitions of Care National Data Set
ACMA is in the development stages of creating an “ACMA Transitions of Care National Data Set” based on the TOC standards and self-assessment tool. If you would like more information, please click below.
Standard 1.0
Identify Patients at Risk for Poor Transitions
Processes are in place to identify individuals at risk for poor transitions so that appropriate measures can be taken by care team members at any location on the continuum to ensure optimum patient health outcomes.
Standard 2.0
Complete a Comprehensive Transition Assessment
Processes are in place to conduct a comprehensive transition assessment for patients identified as high-risk for poor transitions across care settings. Attention is given to further identify patients who may become at risk in the new setting.
Standard 3.0
Perform and Communicate a Medication Reconciliation
Processes are in place to support a reconciled medication list at each care transition point.
Standard 4.0
Establish a dynamic care management plan that addresses all settings throughout the continuum of care.
Processes are in place to support the development of an ongoing care management plan, created with input from the patient, primary caregiver and family. This care plan should be accessible to all care managers and remain with the patient’s regular ambulatory care provider for continuity.
Standard 5.0
Communicate Essential Care Transition Information to Key Stakeholders Across the Continuum of Care
Processes are in place to ensure the timely transfer of essential Transitions of Care (TOC) information to key stakeholders including the caregiver, the regular ambulatory care provider, the payer and the identified episodic care manager in the next care setting
Transitions of Care
Funding and support for the Transitions of Care initiative is provided by