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.