Transitions of Care
Standard 5.0
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
Funding and support for the Transitions of Care initiative is provided by