Transitions of Care

Standard 4.0



Establish a dynamic care management plan that addresses all settings throughout the continuum of care.

Processes are in place to support the development of an ongoing care management plan, created with input from the patient, primary caregiver, and family. This care plan should be accessible to all care managers and remain with the patient’s regular ambulatory care provider for continuity.


Organizations can meet this standard by demonstrating that the care management plan includes the following elements:

Review of all available data, including information gathered from patient self-report or from individuals within the patient’s support network.

Review of goals for care and potential transitions for settings and levels of care with patient/family/caregiver.

Tracking methodology for high-risk patients with an ongoing care management plan.

Identification and documentation of:

  • Regular ambulatory care provider
  • Health plan benefits and known barriers
  • Designated caregivers
  • Pharmacy/pharmacies used
  • Specialty care providers
  • Home health/home care provider
  • Social service agencies
  • Known episodic or longitudinal care manager

Identification and documentation of advance care planning documents.

Pharmacy consult as appropriate, with documentation of the outcome and evidence of patient/family/caregiver awareness and understanding of the necessary course of action.

Evidence of timely reassessments as the patient moves across care settings.

Documentation of referrals and linkages to community resources and services.

Documentation of patient and support network agreement to referrals and linkages.

Supporting documentation that services and referrals meet the expectations and requirements of payers.

Utilization of available technologies to maximize accuracy with the ability to efficiently transfer care plan information across the care continuum (patient, caregiver, provider, and longitudinal/episodic care managers), using secure data exchanges and paperless systems when possible.

Identification and documentation of episodic or longitudinal care managers coordinating transitions across the care continuum.

Communication and sharing of the care plan to known episodic or longitudinal care managers across the care continuum.

Whenever possible, the care management plan is shared through secure data exchanges to create a paperless system of care planning across the care continuum.

Roles & Terms

Roles vary by care settings, but the following personnel may be involved in the development of an ongoing care management plan.

Acute care: RN, LCSW, MSW, MD, APC, PharmD

Ambulatory care: PCP, RN, APC, LCSW, MSW, Practice manager, PharmD

Skilled nursing facility: RN, MDS coordinator, LCSW, MSW, administrator, APC, PharmD

Home Health: RN, LCSW, MSW, APC, PharmD

Hospice: RN, LCSW, MSW, APC, PharmD, APC

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

Ambulatory Care Provider

This is the care provider who provides regular ambulatory care to a patient outside of an acute or institutional setting. This may be a primary care physician (PCP), an advanced practice clinician (APC) or other licensed healthcare provider appropriate to the setting.

Advance Care Planning documents

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

Episodic Care Manager

This is the person at a specific level of care who will be the care manager for the patient in that setting.

Longitudinal Care Manager

This is the clinician who is accountable, over the course of time, to oversee care coordination across various care settings for high-risk patients. The clinician may be a primary care provider (PCP), ambulatory care provider, payer or community provider.

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.