Journal Of Healthcare Information Management

cally understood as “transitions.” For the elderly, work was directed at multi-provid-er and multi-site coordination. 2, 3, 4, 5 Pediatrics dealt with the transition to adult care. Hospitals scrutinized readmissions. 6, 7 Organ transplant, cancer, trauma, imaging, and other facilities required transport and logistics among teams of providers.

Today, mobile patients; provider, hospi-
tal, and delivery system integration and
disintegration; and payment, regulatory,
Many have drawn attention to shortcom-
ings in care transitions. Coleman, 8, 9 sug-
gested the following components of effec-
tive transitions:

■ n Communication between the sending and receiving clinicians:

■ ● A common plan of care

■ ● A summary of care provided by the
sending institution

■ ● The patient’s goals, preferences, and advance directives

■ ● Updated list of problems, baseline exam, cognitive functional status, medications, and allergies

■ ● Contact information for the patient’s caregiver(s) and primary provider

■ n Preparation of the patient and caregiver for what to expect at the next site of care

■ n Reconciliation of the patient’s current medications and those before the initial transfer

■ n A follow-up plan to complete outstanding tests and appointments

■ n An explicit discussion with the patient
and caregiver regarding symptoms to mon-
itor and who to contact if the medical condi-
tion worsens
In 2008, the Case Management Society
of America (CMSA) (while the CMSA’s
history draws heavily from the profes-
sions working in discharge planning, such
as RNs and MSWs, its scope of interest is
broader than just the acute care arena.)
convened the National Transitions of Care
Coalition (NTOCC). NTOCC produced a
set of standards10 in a format that reflected
Donabedian’s model for evaluating quality
of care. 11

A. Structure Elements

1. Accountable provider at all points of care

2. A tool for plan of care

3. Use of integrated and interoperable health IT B. Process Elements

4. Specific care team processes

5. Information transfer/communica-tion between providers and care settings C. Outcome Elements

7. Patient and family experience and satisfaction

8. Provider’s experience and satisfaction

9. Healthcare utilization and costs
The American College of Physicians,
Society of General Internal Medicine,
Society of Hospital Medicine, American

ABSTRACT

BACKGROUND

Transitions of care (TOC) are movements of patients between healthcare locations, providers, or levels of care. Care transitions provide opportunities for errors and adverse events, which impact patient safety and healthcare system effectiveness and cost. While some TOC scenarios are well studied (e.g., hospital discharge), the lack of a general TOC model makes it difficult for planners and analysts to share and extend guidelines across different scenarios.

OBJECTIVES

The authors worked to develop a unified conceptual framework for understanding TOC processes, which would be useful for planning and evaluating care transitions in a wide variety of healthcare settings.

PROCESS

The authors were members of the TOC Work Group of the Ambulatory Information Systems Committee convened by the Healthcare Information and Management Systems Society (HIMSS). They have refined and expanded the TOC Framework developed by that group as part of its 2015 report.

OUTCOME

A set of elements was identified relevant to TOC across a wide variety of healthcare scenarios. These included near-real-time scenarios such as handoffs and sign-outs; asynchronous scenarios such as hospital discharges, transfers, transports and referrals; and long latency scenarios such as planning for future procedures and contingencies. The list of elements and illustrative scenarios are offered for comment on the HIMSS website.

CONCLUSIONS

The authors believe this is the first general framework to offer a unified perspective on TOC applicable in all healthcare settings and circumstances. It enables planners and evaluators a format for sharing insights and methods and comparing outcomes across disparate settings.