Care Transition Programs

Care transitions occur when a patient moves from one health care provider or setting to another. Examples would be a patient that was discharged from the hospital to home or to a nursing home, or from a nursing home to home; they may be at risk for readmission back to the hospital if they develop a complication. These complications are often preventable.

Policies and procedures will:

  • Identify community-specific root causes of readmissions
  • Define the target population
  • Have a strategy for identifying high risk patients
  • Specify care transition interventions and services that will address readmissions, including strategies for improving provider communications and improving patient participation
  • Describe how care transition strategies will be adapted to the individual patient (learning ability, health literacy, language and cultural issues, etc.) and how other community and social supports will be utilized (if appropriate) to enhance beneficiaries’ post-hospitalization outcomes
  • Provide an implementation plan with goals and follow-up
  • Typically will have a documentation system that allows for determining the amount of money saved by preventing readmissions.

Steps would include:

  • When transition services would begin (before discharge, at discharge, within 24 hours of discharge, etc.)
  • Interaction and communication with discharge providers,outpatient providers and the primary care provider, including documentation
  • Performing medication therapy management services (reference white paper: and providing a current medication list including OTC products to the patient and the provider(s)
  • Self-management and support information specific to the patient that includes follow-up steps with outpatient providers
  • Educational counseling and materials that are appropriate to the patient to ensure patient understands the potential additional health problems or  what would indicate a deteriorating condition

Medication reconciliation includes:

  • Obtaining, verifying, and documenting the patient’s current prescription and over-the-counter medications—including vitamins, supplements, eye drops, creams, ointments, and herbals—from both the patient and the provider(s) and performing an assessment to resolve discrepancies.
  • Considering patient medication additions and discontinuations prior to transition and resolving discrepancies.
  • Providing an updated medication list including OTC products to both the patient and the provider(s) and communicating the importance of managing medication information to the patient.