Standard 1.0

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.

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 care coordinators across the 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 health care resources
• Polypharmacy and/or 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 payor data sets.

Optimization of available technologies to deliver the services associated with the standard.

Develop action plan in conjunction with payor, if possible.