Transitions of Care
Guiding Principles
Principles for Desired Outcomes
Transitions of Care standards will:
- Deliver a framework of minimum elements necessary to support seamless transitions of care between settings across the care continuum.
- Provide coordinated, efficient, cost-effective, collaborative care transitions, which align with existing quality and safety measures.
- Standardize practices to guide transitions between care settings.
- Align with regulations across all delivery care settings.
- Ensure patient and family engagement in planning and executing all transitions.
- Incorporate Social Determinants of Health assessments for those at risk for ineffective care transitions.
- Identify and partner with community and other available resources.
- Expand access to relevant information and maximize the use of available technology.
The standards apply across all care settings and reflect the minimum elements necessary to create successful transitions.
Each standard describes both the structures and the services required to meet that standard.
Standard 1.0
Identify patients at risk for ineffective Transitions of Care
Standard 2.0
Complete a comprehensive Transition assessment
Standard 3.0
Perform, communicate, and implement findings from a Medication Reconciliation
Standard 4.0
Establish a dynamic care plan that addresses all settings across the care continuum
Standard 5.0
Communicate essential care transition information to key stakeholders across the care continuum
Transitions of Care
Funding and support for the Transitions of Care initiative is provided by