Standard 1.0

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.