A. Transition of care involves the movement of a patient from one health care practitioner or setting to another as the patient’s condition and care needs change.

B. The focus on improving transitions of care has been the work of several researchers starting in the early 1990s such as:

C. The passage of the Patient Protection and Affordable Care Act (PPACA) of 2010 brought a much higher visibility to the issues of transitions of care and elevated the recognition of case management and its contribution to outcomes. PPACA highlighted the need for case management interventions to bring about the improvement in care coordination and transitions within the continuum of care.

D. One of the challenges for case managers is recognition of their roles within the interdisciplinary health care teams and appropriate attribution for their case management participation, especially as documented in the patient’s electronic medical record reflective of their key care interventions (Box 10-2).

A. The Case Management Society of America (CMSA) describes in its standards of practice for case management (CMSA, 2010) that case management practice extends across all health care settings, including payer, provider, government, employer, community, and home
environment. The standards also recognize that it is natural for patients to transition among these care settings based on their care needs.

B. Professional case managers are essential to improving transitions of care and the patients’ experiences during transitions. They provide interventions for care coordination across the continuum of care and bring value in improving clinical and financial outcomes.

C. The case manager works at the top of his/her license addressing professional case management practice, which requires knowledge of and proficiency in the following practice standards described by CMSA (CMSA, 2010):

A. Accountable Care Organization (ACO)—The ACO concept is evolving, but it is generally considered that an ACO is as a set of health care providers, including primary care physicians, specialists, and hospitals, working together collaboratively and accepting collective accountability for the cost and quality of care delivered to a population of patients (Accountable Care Facts, 2015).

B. Accreditation—Accreditation is an evaluative, rigorous, transparent, and comprehensive process in which a health care organization undergoes an examination of its systems, processes, and performance by an impartial external organization to ensure that it is conducting business in a manner that meets predetermined criteria and is consistent with the standards set forth by the accrediting organization (URAC, 2015a). Criteria may include standards of care and operations, quality, safety, outcomes management, and performance improvement.

C. Care Coordination—The deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care provision, to facilitate the appropriate delivery of health care services.

D. Care Plan—A written individual plan of care, developed from an evidenced assessment with the patient, family caregiver, and interdisciplinary health care team. The care plan should detail the patient’s health, behavioral, social and health system needs, and personal preferences.

E. Certification—Is a process by which an agency or association grants recognition to an individual who has met certain predetermined qualifications specified by that agency or association and usually relevant to the specialty.

F. Care Team—A collaborative care team for a given patient consisting of the various health care professionals—physicians, advanced practice nurses, pharmacists, clinical nurses, social workers, case managers, and other allied health care professionals.

G. Discharge Planning—Conducted to plan for when a patient leaves a care setting or health care encounter. The health care professional(s) and the patient participate in discharge planning activities that aim to identify the most appropriate setting the patient may access and the necessary services and resources required (Centers for Medicare and Medicaid, 2014a).

H. Handover—Sometimes also referred to as handoff. It is the communication between two parties that ensures consistent patient care
and requires both the sender and receiver to understand the information and have the ability to clarify any questions or concerns. Although handovers have been practiced by nurses during shift changes for many years, the term/concept is now being used to enhance communication during transitions of care and among various health care providers and patients/families.

I. Health Literacy—Defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions and services needed to prevent or treat illness (Health Resources and Services Administration, 2015). Low health literacy is more prevalent among older adults, minority populations, those who have low socioeconomic status, and medically underserved populations. Patients with low health literacy may have difficulty being engaged in own health care and may experience certain challenges (Box 10-3).

J. Interprofessional Practice (IPP)—A collaborative practice that occurs when various health care providers work with people from within their own profession, with people outside their profession, and with patients and their families (Canadian Interprofessional Health Collaborative, 2009) for the purpose of meeting patient care goals and needs.

K. Patient-Centered Care—The Institute of Medicine (IOM) defines patientcentered care as providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions (2001).

L. Patient-Centered Medical Home (PCMH)—A care delivery model whereby patient treatment is coordinated through the primary care physician to ensure the patient receives the necessary care when needed and where needed, in a manner the patient can understand. PCMH takes responsibility for coordinating the patient’s health care plan and needed resources across care settings and services over time in consultation and collaboration with the patient and family caregiver. The interdisciplinary
health care team in the PCMH setting has a number of responsibilities toward patient care such as those summarized in Box 10-5 (American College of Physicians, 2007).

M. Transitions of Care—Refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness or an episode of care. For example, in the course of an exacerbation of a chronic illness, a patient may receive care from a primary care physician or specialist in an outpatient setting and then transition to a hospital physician and nursing team during an inpatient admission before moving on to
yet another care team at a skilled nursing facility. Finally, the patient may return home where he/she receives care from a visiting nurse. Each of these shifts from care providers and settings is defined as a care transition (Care Transitions Intervention Program, 2015).

A. The National Transitions of Care Coalition (NTOCC) was founded in 2006. It consists of a group of professional organizations, associations, and individuals who have joined together to address actual and potential problems concerning transitions of care: the movement of patients from one practice setting or provider to another. NTOCC believes that during these transitions, poor communication and coordination between professionals, patients, and caregivers can lead to serious and even lifethreatening situations. In addition, these inefficiencies may result in wasted resources and frustrate health care consumers (NTOCC, 2015).

B. One of the key tools or materials NTOCC developed based on available evidence and expert opinions is the Transitions Bundle, which consists of “seven essential intervention categories” for improving transitions of care (NTOCC, 2011). The bundle provides examples of essential care transition intervention strategies that health care professionals interested in implementing improvements in care transition can consider for use (Box 10-6).

C. The concepts of the Care Transitions Bundle apply to all care transition exchanges across providers and care settings. They are categorized into
main topics containing concrete practices and descriptive language. Descriptions of each of the elements and examples are provided below to aid health care professionals in easily adopting these strategies.

D. Bundle Element 1: Medication Management