Transitions of Care
Standard 2.0
2.0
Complete a Comprehensive Transition Assessment
Processes are in place to conduct a comprehensive transition assessment for patients identified as high-risk for ineffective transitions across care settings. Attention is given to further identify patients who may become at risk in the new setting due to physical, mental, or social barriers during transition from one setting to another.
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 of care for transitions to other settings or 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. (Individual and Family Self-Management Theory)
Review of social drivers of health risk factors and revise action plan accordingly.
Review a medication reconciliation, and review of patient’s medication adherence. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7319010/
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 health care team.
Communication of assessment summary to next care setting.
Roles & Terms
Acute Care: RN, LCSW, MSW
Ambulatory Care: RN, LCSW, MSW, MD, APP
(unlicensed personnel may collect data only)
Skilled Nursing Facility: RN, LPN/LVN, LCSW, MSW
Home Health: RN, LCSW, MSW, APP
Health Plans/ACO: RN, LPN, LCSW, MSW, MD, PharmD
Community Health Worker
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. IFSMT (Individual and Family Self-Management Theory) https://uwm.edu/nursing/centers-institutes/self-management-science-center/theory/
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 defines social drivers of health as “the circumstances in which you were born, live, work, grow, age, play, all of those things.”
Advance Care Planning documents
Documents include advance directives, living wills or Power of Attorney. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/advancecareplanning.pdf