that occur before, during, or after the transition. Steps may be distributed among a
team but having a single coordinator has
advantages. Sub-components of this element include ensuring appropriateness of
the transition and readiness of the patient,
caregivers and the receiver; assuring that
clinical information, instructions, plans
and other relevant data are transmitted to
all who need to know; and obtaining consent and agreement of the parties as appropriate. Responsibility may include providing oversight and documenting the process
and making adjustments for contingencies
and problems.
10. Communication medium and
mode. Through what medium is communication accomplished between Initiator
and Receiver? Spoken, written, electronic?
Synchronous, asynchronous, real-time,
delayed? Is there an intermediary responsible for storing, forwarding, filtering, preserving?
11. Latency. Over what timeframe will
the transition occur? Hours, days, years?
What is the tempo of the transition? Is there
a delay between initiation and resolution,
satisfaction, and completion?
12. Complexity. How complex is the
transition? How many steps/components
in the process? How many people involved?
How much payload? How “fragile” is the
patient/process? Are there hazards to
patient or providers?
13. Priority. How urgent is the transition? Routine, urgent, critical? This may
need to take into account other transitions
and activities competing for resources.
14. Notices, acceptance, acknowledgment. How does the Initiator notify
the Receiver of the transition, and how does
the Receiver respond? Closing the loop may
take the form of an administrative “
handshake.” What format and channel are used?
When is notification unnecessary? What
happens when a referral, consult, or transfer is declined?
15. Tracking and documentation. How
is the transition tracked and documented?
This category includes the process records
of all the others. What other metrics are rel-
evant? How is completion tracked? How
would a failure be discovered? (Rules,
This element falls into the category of
“metadata.” End-to-end documentation
about the course of the transition is valu-
able to quality reviewers, policy research-
ers, and resource planners.
16. Patient experience. What is the
patient’s experience, in terms of satisfaction, comprehension, clinical effectiveness,
effort, etc.?
THE SCENARIOS
The validity of the Framework will be
demonstrated by how well it helps users
produce outcomes they seek for the care
transitions their organization performs.
We have published an initial set of TOC use
cases on the HIMSS website, 24 to illustrate
and test the usefulness and plausibility of
the Framework across different scenarios,
for example:
1. Hospitalist discharges patient from
community hospital to home after pneumonia
2. Patient makes appointment (
self-referral) to a specialist
3. Hospital discharges an 85-year old
patient to SNF after surgery for a hip fracture
4. PCP refers patient to specialist
Every clinical setting has methods, poli-
cies, and practices to facilitate care transi-
tions and protect patients in the process.
Since handoffs within institutions occur
tens of thousands of times per day, a great
deal of work has gone into tools and tem-
plates to help them go well. This is also
true of the common scenarios of hospital
discharge to long-term care, ED to hospital
admission, and ED to home. Yet, these are
only a few examples in a larger universe.
Tools well designed for some scenarios
may be transferrable to others or may be
completely inapplicable. Among a large
catalog of tools are structured verbal com-
munications between nursing staff and
physicians, verbal and written templates
for handoffs by nurses and house staff,
referral and discharge summary forms,
electronic messaging and notification sys-
tems, and standards for data exchange.
Our plan is to maintain a library of scenarios submitted from, and relevant to, a
spectrum of organizations and practitioners. This will allow reality testing and
opportunity to improve the Framework
and serve as a reference set of deeply analyzed use cases for practitioners, policy
makers, and researchers.
IMPLICATIONS AND FUTURE DIRECTION
OF THE TOC FRAMEWORK
The Framework is intended as a general
model of care transitions across the spectrum of healthcare. Its first goal is to be a
checklist of practices that may help organizations, practitioners, patients, and other
participants prospectively improve safety,
efficiency, and effectiveness when moving
persons, things, and information between
locations, providers, or levels of care. Its
second goal is to offer a set of retrospective
measures that may help appraise the success and quality of care transitions among
different facilities, populations, and conditions.
In both respects, we believe there is a
need to harmonize practices and metrics
developed for disparate purposes so that
insights, infrastructure, and technology
useful for one kind of transition can more
readily be adapted to others. This is the
main value to be gained from a unified
analysis of care transitions, which we think
we have achieved, in a “version 1.0” form.
There needs to be realistic agreement
between actions proposed to be taken
and measures proposed to judge them.
By combining both perspectives in the
Framework, we hope they can develop
together. We anticipate that there are scenarios – and perhaps even Elements – in
some settings that the Framework has not
foreseen. Its robustness will be tested by
how well it accommodates adjustments.
However, we hope future versions can
build on the essential form we have suggested and the addition of new scenarios
or best practices from the healthcare community. JHIM
