Self Assessment

 

Be the First to Receive National Data and Findings!

ACMA is identifying participants for the “ACMA Transitions of Care National Data Set” based on the TOC standards and self-assessment tool. Participants will contribute to and receive a report on the data and findings. All submitted information will be de-identified and aggregated.

To learn more and request consideration for participation 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

11701 West 36th Street
Little Rock, Arkansas 72211

Sponsored by

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