BACKGROUND
One of the most dangerous procedures
in healthcare is transitions of care (TOC)
for patients between locations, providers,
or levels of care. Examples of transitions
include handoffs and transports within
facilities; transfers between facilities; referrals and consultations; and discharges,
interruptions and termination of care. Even
modestly complex patients today move frequently through networks of encounters,
consultants, tests, and therapies administered by teams under pressure in today’s
pay for value environment. The elderly and
patients with co-morbid chronic conditions, multiple providers and medications,
are at highest risk.1
The “Transition of Care Framework”
was developed by the TOC Work Group
of the Care Coordination Task Force for
the HIMSS 2015 Ambulatory IS Commit-
tee. It provides a general analytic model
addressing important variables for any
type of patient transition in a healthcare
context.
The seriousness of care transitions has
been recognized by many experts, and recommendations for managing transitions
in several settings have been developed
by guideline setting organizations. 2, 3, 4, 5
However, no current models address the
structural, administrative, workflow, and
informational components of the TOC process across a comprehensive spectrum of
situations. Most research and development
efforts have focused on limited scenarios,
such as house staff handoffs, ED admits,
and hospital discharges to home or long
term care.
Using the term Transitions in Patient Care,
a PubMed search on 12/13/15 retrieved 1,943
citations between 1997 and 2015, of which
1,348 (69.4%) were published in the last 6
years (see Table 1).
Before 1990, TOC predominantly meant
discharge planning for hospital patients.
Increasingly, managed care directed attention to post-acute transitions, step down
care, rehabilitation, and home care. Insurance networks introduced pre-certification
processes. Advanced emergency and
transport services were rapidly developing
during this period, but these were not typi-
A General
Framework for
Managing Care
Transitions
Michael S. Victoroff, MD, Henry L. Mayers, MCP, PMP, FHIMSS, CPHIMS,
and Antonio P. Linares, MD, FAAFP
TOC Articles in
PubMed
Decade of 1970 2
Decade of 1980 19
Decade of 1990 39
Decade of 2000 535
2010-2014 1,068
2015 280
