Transitions of Care
Standards Framework
Standard 1.0
Standard 4.0
Establish a dynamic care management plan that addresses all settings throughout the continuum of care
Transitions of Care Standards
The Transitions of Care Standards are intended as a common framework for all healthcare settings, to foster effective, high quality and efficient care transitions, and are designed in such a way that:
- They may be applied across care settings.
- They help organizations assess, quantify and identify gaps in their current care transition work plan.
- Leaders may use them to identify opportunities to modify current transition of care processes to demonstrate return on investment (ROI) for care transition management.
- They use recommended measures to guide relevant data collection.
- They help organizations review and understand care transition related roles and expectations occurs across care settings.
- They help establish relationships and connections across all health care and community settings.
- They build a foundation to support longitudinal care management strategies.
- They provide a framework to evaluate return on investment (ROI) of care transition efforts as a mechanism to reduce utilization and enhance quality and patient experience (Value Based Care ROI)
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.
Health care entities can meet this standard through evidence of the following essential health risk identification elements:
Use of a validated health risk assessment tool that meets regulatory requirements for the care delivery setting and assigns a quantifiable risk score that can be measured.
Communication of health risk assessment findings to known episodic care managers across the care continuum.
Reassessment at each episode of care or transition to a new care setting.
Implementation of performance improvement processes to identify root causes for failed transition or readmission.
Screening for medical, behavioral and social factors associated with high-risk for poor transitions, including social determinants of health.
- Frequent facility admissions and/or inappropriate utilization of health care resources
- Polypharmacy and/or poor medication adherence
- Multiple co-morbidities and/or 2+ chronic conditions
- Cognitive or functional impairments
- Behavioral health issues
- Social determinants
Incorporation of proactive predictive-risk modeling of specific patient populations through the analysis of internal and external information such as state, community, institutional or payer data sets.
Optimization of available technologies to deliver the services associated with the standard.
Roles & Terms
Unlicensed personnel, based on the care setting, may complete the performance and documentation of the health risk assessment. This differs from the clinical assessment, which must be performed by licensed/credentialed professionals.
Health Risk Assessment Tool
A health risk assessment (HRA) is a health questionnaire used to provide individuals with an evaluation of their health risks and quality of life.
Episodic Care Manager
The person at a specific level of care who will be the care manager for the patient in that setting.
Social Determinants of Health
As defined by the World Health Organization (WHO), social determinants of health are the conditions in which people are born, grow, live, work and age. These conditions may include: financial or economic limitations, poor health literacy, housing/food instability, lack of social support, unreliable transportation, and unhealthy behaviors. The circumstances are shaped by the distribution of money, power and resources at global, national and local levels.
Roles & Terms
Acute care: RN, LCSW, MSW
Ambulatory care: RN, LCSW, MSW, MD, APC
(MA may collect data but may not assess)
Skilled nursing facility: RN, LCSW, MSW
Home Health: RN, LCSW, MSW, APC
Hospice: RN, LCSW, MSW, APC
Health plans/ACO: RN, LPN, LCSW, MSW, MD, PharmD
Self-Management Ability
Refers to a patient’s ability to recognize symptoms and warning signs, identify the actions to take, know why medications have been prescribed and how to take them.
Social Determinants of Health
As defined by the World Health Organization (WHO), social determinants of health are the conditions in which people are born, grow, live, work and age. These conditions may include: financial or economic limitations, poor health literacy, housing/food instability, lack of social support, unreliable transportation, and unhealthy behaviors. The circumstances are shaped by the distribution of money, power and resources at global, national and local levels.
Designated Decision Maker
The family member(s), lay caregiver, surrogate or advocate who is authorized to make health care and other decisions for the patient.
Advance Care Planning documents
Documents include advance directives, living wills or Power of Attorney (POA).
Instrumental Activities of Daily Living
the activities often performed by a person who is living independently in a community setting during the course of a normal day, such as managing money, shopping, telephone use, travel in community, housekeeping, preparing meals, and taking medications correctly.1
1Mosby’s Medical Dictionary, 9th edition. © 2009, Elsevier
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.
Organizations can meet this standard by showing evidence that a comprehensive transition assessment is completed, and that the following elements are included:
Review of relevant healthcare utilization across all care settings including recent provider orders, payer benefits, preferred networks, and claims data when available.
Solicit patient, family and caregiver goals for care and potential transitions for settings and levels of care.
Evaluate and document patient/family/caregiver engagement and understanding of current health status.
Assess self-management abilities, which may include activities of daily living (ADL), instrumental activities of daily living (IADL), patient’s decision-making ability and/or willingness to participate in care planning discussions.
Review of social determinants of health.
Completion of a medication reconciliation, and review of patient’s medication adherence.
Review and documentation of patient care goals according to the regulations that govern the care setting and, when appropriate, identify the patient’s designated decision maker.
Examination of advance care planning documents ensuring they are current, complete and available to the healthcare team.
Communication of assessment summary to next care setting.
3.0
Perform and Communicate a Medication Reconciliation
Processes are in place to support a reconciled medication list at each care transition point.
Organizations can meet this standard by showing evidence that a comprehensive transition assessment is completed, and that the following elements are included:
Compilation of a full medication history, including both prescribed and non-prescribed medications, from all available sources, including:
- EHR and discharge summary
- E-prescribing records
- Claims data
- Paper records from other sites of care and providers
- Self-reported from patient or caregiver
- Patient’s pharmacy
- Regular ambulatory care provider
Identification of patients who may be at high-risk for medication related adverse events or non-adherence due to polypharmacy, opioids, high-cost / specialty drugs.
Review of medication history against active medications in the current setting.
Verification of medication list accuracy with patient or caregiver.
Verification of medication adherence with patient or caregiver, and assessment and documentation of any adherence and access barriers, including coverage, affordability, or transportation.
Document all medication reconciliation activities in the medical record, using applicable coding.
Roles & Terms
The treating provider (MD, DO) involved at the time of transition must be the party who is accountable for the reconciliation. The medication review may be performed by a designated clinical team member. The clinical pharmacist is uniquely qualified to make recommendations to optimize medication therapy and avoid potential adverse events such as drug-drug interactions.
Non-licensed providers may gather information but should neither perform medication reconciliation nor provide clinical recommendations.
Ambulatory Care Provider
The care provider who provides regular ambulatory care to a patient outside of an acute or institutional setting. This may be a PCP, ACP or other licensed healthcare provider appropriate to the setting.
Roles & Terms
Roles vary by care settings, but the following personnel may be involved in the development of an ongoing care management plan.
Acute care: RN, LCSW, MSW, MD, APC, PharmD
Ambulatory care: PCP, RN, APC, LCSW, MSW, Practice manager, PharmD
Skilled nursing facility: RN, MDS coordinator, LCSW, MSW, administrator, APC, PharmD
Home Health: RN, LCSW, MSW, APC, PharmD
Hospice: RN, LCSW, MSW, APC, PharmD, APC
Health plans/ACO: RN, LCSW, MSW, LPN, PharmD
Ambulatory Care Provider
This is the care provider who provides regular ambulatory care to a patient outside of an acute or institutional setting. This may be a primary care physician (PCP), an advanced practice clinician (APC) or other licensed healthcare provider appropriate to the setting.
Advance Care Planning documents
Documents include advance directives, living wills or Power of Attorney (POA).
Episodic Care Manager
This is the person at a specific level of care who will be the care manager for the patient in that setting.
Longitudinal Care Manager
This is the clinician who is accountable, over the course of time, to oversee care coordination across various care settings for high-risk patients. The clinician may be a primary care provider (PCP), ambulatory care provider, payer or community provider.
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 a for ambulatory care provider continuity.
Organizations can meet this standard by demonstrating that the care management plan includes the following elements:
Review of all available data, including information gathered from patient self-report or from individuals within the patient’s support network.
Review of goals for care and potential transitions for settings and levels of care with patient/family/caregiver.
Tracking methodology for high-risk patients with an ongoing care management plan.
Identification and documentation of:
- Regular ambulatory care provider
- Health plan benefits and known barriers
- Designated caregivers
- Pharmacy/pharmacies used
- Specialty care providers
- Home health/home care provider
- Social service agencies
- Known episodic or longitudinal care manager
Identification and documentation of advance care planning documents.
Pharmacy consult as appropriate, with documentation of the outcome and evidence of patient/family/caregiver awareness and understanding of the necessary course of action.
Evidence of timely reassessments as the patient moves across care settings.
Documentation of referrals and linkages to community resources and services.
Documentation of patient and support network agreement to referrals and linkages.
Supporting documentation that services and referrals meet the expectations and requirements of payers.
Utilization of available technologies to maximize accuracy with the ability to efficiently transfer care plan information across the care continuum (patient, caregiver, provider, and longitudinal/episodic care managers), using secure data exchanges and paperless systems when possible.
Identification and documentation of episodic or longitudinal care managers coordinating transitions across the care continuum.
Communication and sharing of the care plan to known episodic or longitudinal care managers across the care continuum.
Whenever possible, the care management plan is shared through secure data exchanges to create a paperless system of care planning across the care continuum.
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.
Organizations can meet this standard by showing evidence that:
Appropriate TOC stakeholders are identified. These stakeholders may include: patient and caregivers, regular ambulatory care provider, pharmacists in all relevant settings, care manager at the next care setting, payer, and community service agencies.
Communications are deployed electronically whenever possible.
Information transfer includes an acknowledgement of receipt.
Essential transition information is communicated including both clinical and social determinants of health. Clinical determinants should include, as appropriate:
- Diagnosis, co-morbidities, chronic condition
- Medications, known history of adherence
- Potential for polypharmacy, opioid or substance abuse
- Labs and other tests
- Appointments
- Cognitive or functional impairments
- Behavioral health issues
Roles & Terms
Roles vary by care setting, but the following personnel may be involved in the development of an ongoing care management plan.
Acute care: RN, LCSW, MSW, APC, PharmD
Ambulatory care: MD, RN, LPN, LCSW, MSW, PharmD
Emergency care: RN, EMT, paramedic, PharmD
Skilled nursing facility: MD, APC, RN, LPN, LCSW, MSW, PharmD
Home Health: RN, LCSW, MSW, LPN, PharmD, APC
Hospice: RN, LCSW, MSW, LPN, PharmD, APC
Health plans/ACO: RN, LPN, LCSW, MSW, PharmD
Non-licensed staff may transfer information via fax or secure portal
Ambulatory Care Provider
This is the care provider who provides regular ambulatory care to a patient outside of an acute or institutional setting. This may be a Primary Care Physician (PCP), Advanced Primary Care (APC) or other licensed healthcare provider appropriate to the setting.
Episodic Care Manager
This is the person at a specific level of care who will be the care manager for the patient in that setting.
Social Determinants of Health
As defined by the World Health Organization (WHO), social determinants of health are the conditions in which people are born, grow, live, work and age. These conditions may include: financial or economic limitations, poor health literacy, housing/food instability, lack of social support, unreliable transportation, and unhealthy behaviors. The circumstances are shaped by the distribution of money, power and resources at global, national and local levels.
Transitions of Care
Funding and support for the Transitions of Care initiative is provided by