Learning Collaborative



Transitions of Care
Learning Collaborative 

ACMA developed the Transitions of Care (TOC) Standards to guide care managers and other health care professionals in identifying and implementing the necessary processes and approaches to ensure smooth transitions. 

Value-based care has gained traction and more attention is being paid to care transitions; not only to improve patient outcomes, but to reduce costs related to avoidable readmissions, emergency department (ED) utilization, and other expensive services.

From the American Case Management Association’s (ACMA) perspective, heightened attention on care transitions is a very welcome development. ACMA recognizes the importance of care coordination to providing a safe and effective care transition across the continuum. 

ACMA launched the TOC Learning Collaborative, which ran from December 2019 to June 2020.
The primary collaborative goals were:

  • Completion of pre- and post-assessment tools to evaluate TOC Standard compliance.
  • Testing implementation of the TOC standards across various health systems.
  • Disseminate innovative and effective practices, as well as challenges and barriers, that may impact the implementation of the TOC standards.



ACMA thanks the leaders of the six organizations who participated in the TOC Learning Collaborative. Their commitment to the project, pre- and post-assessment, and utilization of TOC Standards, especially during the initial COVID-19 pandemic, is a tremendous contribution to improving care transitions. We could not advance and enhance safe care transitions for our patients without these committed leaders and their organizations. We also acknowledge and appreciate Pfizer for their continued sponsorship of the TOC Standards and the support provided to conduct this ACMA Learning Collaborative. 

Read the TOC Tool Kit

View detailed Self-Assessments for each of the standards in the Implementation Tab.

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.