Transitions of Care

Standard 5.0



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

Processes are in place to ensure the timely transfer of essential TOC information to key stakeholders including the caregiver, the regular ambulatory care provider, the payer and the identified episodic care manager 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 provider, pharmacists in all relevant settings, care manager at the next care setting, payer, and community service agencies.

A standardized, securely maintained framework for communication transfer is used

Communications are deployed electronically whenever possible.

Information transfer includes an acknowledgement of receipt.

Essential transition information is communicated including both clinical and social determinants of health. Clinical determinants should include, as appropriate:

  • Diagnosis, co-morbidities, chronic condition
  • Medications, known history of adherence
  • Potential for polypharmacy, opioid or substance abuse
  • Labs and other tests
  • Appointments
  • Cognitive or functional impairments
  • Behavioral health issues

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, APC, PharmD

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

Emergency care: RN, EMT, paramedic, PharmD

Skilled nursing facility: MD, APC, RN, LPN, LCSW, MSW, PharmD

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

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

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

Non-licensed staff may transfer information via fax or secure portal

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), Advanced Primary Care (APC) or other licensed healthcare provider appropriate to the setting.

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.

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.

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.