Transitions of Care

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 appropriate measures can be taken by care team members at any location across the continuum to ensure optimum patient health outcomes.


Healthcare 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 care coordinators across the care continuum.

Reassessment at each episode of care, or transition to a new care setting for those identified as at-risk.

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 ineffective transitions, including social determinants of health.

  • Frequent facility admissions and/or inappropriate utilization of healthcare resources
  • Polypharmacy and/or poor inadequate medication adherence
  • Multiple co-morbidities and/or 2+ chronic conditions
  • Cognitive or functional impairments
  • Behavioral health issues
  • Social determinant of health assessment tool

Incorporation of predictive-risk modeling of specific patient populations >18 years of age 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.


Develop action plan in conjunction with payor, if possible. 

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.

Care Coordinator

The person at a specific level of care who provides care coordination/navigation management 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.

Social Drivers

The World Health Organization (WHO) defines social drivers of health “as the circumstances in which you were born, live, work, grow, age, place, all of those things.”

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.