Transitions of Care

Standard 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.


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.

Episodic Care Manager

The person at a specific level of care who will be the care manager 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.

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.