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 continuum.
- Provide coordinated, efficient, cost effective, collaborative care transitions, aligned with existing and evolving safety and quality measures.
- Standardize practices to guide transitions between levels and settings of care.
- Align with regulations and incentives across care delivery settings and payers.
- Ensure patient and family engagement in planning and execution of all transitions.
- Promote the concept of a longitudinal care manager (provider, payer, or others) for those at high risk for poor 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 poor transitions
Standard 2.0
Complete a comprehensive assessment
Standard 3.0
Perform and communicate a medication reconciliation
Standard 4.0
Establish a dynamic care management plan that addresses all settings throughout the continuum of care
Standard 5.0
Communicate essential care transition information to key stakeholders across the continuum of care
Transitions of Care
Funding and support for the Transitions of Care initiative is provided by