Transitions of Care

Standard 5.0

 

5.0

Communicate Essential Care Transition Information to Key Stakeholders Across the Care Continuum

Processes are in place to ensure the timely transfer of essential Transition of Care (TOC) information to key stakeholders including the caregiver, the regular ambulatory care provider, the payor/Managed Care Organizations, community-based organizations, and the identified care coordinator and/or Payor assigned Care Coordinator in the next care setting.

 

Organizations can meet this standard by showing evidence that:

Appropriate TOC stakeholders are identified. These stakeholders may include patient and caregivers, regular ambulatory care providers, pharmacists in all relevant settings, care coordinators, payors, and community-based organizations at the next care setting.

Communications are deployed electronically whenever possible. A best practice would be to share information bidirectionally between the hospital and the health plan via Electronic Health Record (EHR).

Information transfer includes an acknowledgment of receipt.

A standardized, secure template for communication when transitioning a patient should include: 

  • Diagnosis, co-morbidities, chronic condition
  • Medications, medication adherence
  • Potential for polypharmacy, opioid, or substance abuse
  • Labs and other tests
  • Appointments
  • Cognitive or functional impairments
  • Behavioral health issues
  • Health-related social needs (HRSN) financial, housing, food, literacy, self-efficacy
  • Whenever possible, advance discharge notice to payor
  • Documentation of Z codes
 

Roles & Terms

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

Acute Care: RN, LCSW, MSW, APP, PharmD

Ambulatory Care: MD, RN, LPN, LCSW, MSW, PharmD

Emergency Care: RN, EMT, paramedic, PharmD

Skilled Nursing Facility: MD, APP, RN, LPN, LCSW, MSW, PharmD

Home Health: RN, LCSW, MSW, LPN, PharmD, APP

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

Community Health Worker

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.”

Z Code

SDOH-related Z codes (Z55-Z65) are the ICD-10 CM diagnosis codes used to document SDOH data.

https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/105716

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.