Transitions of Care

Standard 2.0



Complete a Comprehensive Transition Assessment

Processes are in place to conduct a comprehensive transition assessment for patients identified as high-risk for poor transitions across care settings. Attention is given to further identify patients who may become at risk in the new setting.


Organizations can meet this standard by showing evidence that a comprehensive transition assessment is completed, and that the following elements are included:

Review of relevant healthcare utilization across all care settings including recent provider orders, payer benefits, preferred networks, and claims data when available.

Solicit patient, family and caregiver goals for care and potential transitions for settings and levels of care.

Evaluate and document patient/family/caregiver engagement and understanding of current health status.

Assess self-management abilities, which may include activities of daily living (ADL), instrumental activities of daily living (IADL), patient’s decision-making ability and/or willingness to participate in care planning discussions.

Review of social determinants of health.

Completion of a medication reconciliation, and review of patient’s medication adherence.

Review and documentation of patient care goals according to the regulations that govern the care setting and, when appropriate, identify the patient’s designated decision maker.

Examination of advance care planning documents ensuring they are current, complete and available to the healthcare team.

Communication of assessment summary to next care setting.

Roles & Terms

Acute care: RN, LCSW, MSW

Ambulatory care: RN, LCSW, MSW, MD, APC
(MA may collect data but may not assess)

Skilled nursing facility: RN, LCSW, MSW

Home Health: RN, LCSW, MSW, APC

Hospice: RN, LCSW, MSW, APC

Health plans/ACO: RN, LPN, LCSW, MSW, MD, PharmD

Self-Management Ability

Refers to a patient’s ability to recognize symptoms and warning signs, identify the actions to take, know why medications have been prescribed and how to take them.

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.

Designated Decision Maker

The family member(s), lay caregiver, surrogate or advocate who is authorized to make health care and other decisions for the patient.

Advance Care Planning documents

Documents include advance directives, living wills or Power of Attorney (POA).

Instrumental Activities of Daily Living

the activities often performed by a person who is living independently in a community setting during the course of a normal day, such as managing money, shopping, telephone use, travel in community, housekeeping, preparing meals, and taking medications correctly.1

1Mosby’s Medical Dictionary, 9th edition. © 2009, Elsevier

Transitions of Care

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Little Rock, Arkansas 72223

Sponsored by

Funding and support for the Transitions of Care initiative is provided by Pfizer.