Self-Assessment
Standard 1.0
Identify Patients at Risk for Ineffective Transitions of Care
Processes are in place to identify individuals at risk for ineffective transitions so that appropriate measures can be taken care of by care team members at any location across 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 ineffective transitions across care settings. Attention is given to further identify patients who may become at risk in the new setting due to physical, mental, or social barriers during transition from one setting to another.
Standard 3.0
Perform, Communicate, and Implement Findings from a Medication Reconciliation
Processes are in place to support a reconciled medication list at each care transition point, especially in the case of patients at high risk for care transitions.
Standard 4.0
Establish a dynamic care plan that addresses all settings across the care continuum.
People, processes, and technology are in place to support the ongoing care plan, created with input from the patient, primary caregiver, and family. This care plan should be accessible to all care coordinators and remain with the patient’s regular ambulatory care provider, the patient, and the patient’s health care plan.
Standard 5.0
Communicate Essential Care Transition Information to Key Stakeholders Across the Care Continuum
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 payor/Managed Care Organizations, community-based organizations, and the identified care coordinator and Payor assigned Care Coordinator in the next care setting.
Transitions of Care
Funding and support for the Transitions of Care initiative is provided by