1. Presentation Developed for the Academy of Managed Care Pharmacy
Transitions of Care
Presentation Developed for the Academy of Managed Care Pharmacy
Updated: February 2015
As you know, the United States health care system often fails to meet the needs of patients during transitions because care is rushed and responsibility is fragmented, with little communication across care settings and multiple providers.

2. Definition
Transition of Care – Movement of patients from one health care practitioner or setting to another as their condition and care needs change
Occurs at multiple levels
Between settings: Hospital ↔ Sub-acute facility, Hospital ↔ Home
Within settings: ICU ↔ Ward
Across Health States
Curative care ↔ Palliative care/Hospice
Transition of care is the movement of patients from one health care practitioner or setting to another as their condition and care needs change and it necessarily occurs at multiple levels. It occurs 1) within settings, such as primary care and specialty care in the context of care in the community, 2) between settings, such as someone who moves from the hospital to the rehabilitation facility, and it occurs 3) across health states, such as from receiving care in the home to needing care in assisted living.

3. Statistics
1 in 5 patients discharged from hospital to home experience an adverse event within three weeks
1 in 5 Medicare patients readmitted within 30 days after discharge
National Transitions of Care Coalition. Accessed at:

4. Transitions of Care Issues
An older man with atrial fibrillation who takes warfarin for stroke prophylaxis was hospitalized for pneumonia. His dose of warfarin was adjusted during the hospital stay and was not reduced to his usual dose prior to discharge. The new dose turned out to be double his usual dose, and within two days he was rehospitalized with uncontrolled bleeding.

5. Transitions of Care Issues
EXCERPT FROM AN INTERNAL MEMO TO PHYSICIAN STAFF:
“ It was recently noted that medication reconciliation was an issue on one of our patients. Since the patient was critically ill and no family was present, the home medication list was not obtained by the RN at time of presentation. While the physician prepared the discharge reconciliation, it was not identified that the home medication list was never obtained and the patient was confused after discharge about what medications to take….”

6. Reasons for Poor Transitions
Low level of patient activation
Lack of standardized and generally known processes
Inadequate transfer of information across settings
Low level of “patient activation” that stems from low health literacy, lack of self-management skills, motivational issues.
Lack of standardization and generally know processes, which lead to breakdowns in communication during patient discharges and handoffs.
Inadequate transfer of information across settings, continues to cause delays, inaccuracies, omissions

7. Ineffective Transitions = Poor Outcomes
• Wrong treatment
• Delay in diagnosis
• Severe adverse events
• Increased healthcare costs
• Increased length of stay
Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety literature Review Report. March Available at:

8. Poor Transitions of Care Lead to…
• Medication errors
• Increased health care utilization
• Inefficient/duplicative care
• Inadequate patient/caregiver preparation
• Inadequate follow-up care
• Member dissatisfaction

9. What is Transitional Care?
A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care
Based on a comprehensive care plan and availability of well-trained practitioners that have current information about the patient’s goals, preferences and clinical status
Includes:
Logistical arrangements
Education of the patient and family caregiver
Coordination among the health professionals involved in the transition
Coleman EA, Boult C, The American Geriatrics Society Health Care Systems Committee. J Am Geriatr Soc 2003;51:556-7.
Eric Coleman/Chad Boult

10. Essential Interventions
1. Medication management
2. Transition planning
3. Patient and family engagement/education
4. Information transfer
5. Follow-up care
6. Healthcare provider engagement
7. Shared accountability across providers and organizations

11. Partnership for Patients
New nationwide public-private partnership to tackle all forms of harm to patients
Focus: Better care, lower costs
Healthcare providers, health plans, employers, patient advocates, state and federal governments
Improve quality, safety, and affordability of health care for all Americans
In April 2011, the Obama Administration launched Partnership for Patients: Better Care, Lower Costs, an innovative public-private partnership designed to help improve the quality, safety, and affordability of health care by bringing together the leaders of major hospitals, employers, health plans, physicians, nurses, and patient advocates, along with state and federal governments in a shared effort to make hospital care safer, more reliable, and less costly.

12. Partnership for Patients - Goals
Keep patients from getting injured, sicker:
40% reduction in preventable hospital acquired conditions by end of 2014
1.8 million fewer injuries
60,000 lives saved
Help patients heal without complications:
20% reduction in 30-day readmissions by end of 2014
1.6 million patients recover without readmission
Potential to Save $35 billion in three years, including $10 billion for Medicare
The Partnership aims to save lives by stopping millions of preventable injuries and complications in patient care in a 4 year span, comparing 2014 rates to 2010 rates – a very ambitious goal!
If this initiative is successful, the price tag for US health care could be reduced by up to $35 billion, including $10 billion for Medicare.

13. Partnership for Patients – Interim Results
Evaluation found clear evidence for decreased rates of harms in five of the eleven areas:
Obstetrical early elective deliveries (OB-EED)
Readmissions
Adverse drug events (ADE)
Ventilator-associated pneumonia (VAP)
Central line-associated bloodstream infection
Cost estimates as of 2014 suggest cumulative savings of between $3.1 to $4 billion and 15,500 deaths averted
Full report available at -

14. Community-based Care Transitions Program
Goals:
Improve transitions from inpatient hospital setting to home or other care settings
Improve quality of care
Reduce readmissions for high-risk patients
Document measurable savings to Medicare program
More information available at:

15. Community-based Care Transitions Program
Authorized by Section 3026 of Affordable Care Act
CMS’s Innovation Center is providing $300 million in funding to community-based organizations that partner with their local hospital to improve care transition services
November 18, 2011 – first sites selected
72 participating sites
Example Community-based Care Transitions Program (CCTP) partners:
The Atlanta Community-Based Care Transitions Program
The Akron/Canton Area Agency on Aging
The Southwest Ohio Care Transitions Collaborative
The Southern Maine Agency on Aging/Aging and Disability Resource Center
The Area Agency on Aging/Region One Arizona
Elder Services of the Merrimack Valley, Inc.
The Council for Jewish Elderly of Chicago

16. Community-based Care Transitions Program
Provides the opportunity for community-based organizations to partners with hospitals to improve transitions between care settings
$300 million available for this program over 5 years ( )
Currently at capacity and no longer accepting applications. No plans for future sites to be added to the program.
Launched February 2012 and will run for 5 years
Acute Care Hospitals with high readmission rates in partnership with a community based organization
Community-based organizations (CBOs) that provide care transition services
Note: There must always be a partnership between the acute care hospital(s) and the CBO
Preference will be given to proposals that :
include participation in a program administered by the AoA
provide services to medically-underserved populations, small communities and rural areas
Applicants will not be compensated for services already required through the discharge planning process under the Social Security Act and stipulated in the CMS Conditions of Participation.
CBOs will be paid a per eligible discharge rate
Rate is determined by:
the target population
the proposed intervention(s)
the anticipated patient volume
the expected reduction in readmissions (cost savings)
The solicitation and application are available on for CCTP program web page at
Or visit:
Please direct any additional questions to

17. National Transitions of Care Coalition
Founded in 2006 by Case Management Society of America (CMSA) and Sanofi U.S.
Focus: To raise awareness about the importance of transitions in improving health care quality, reducing medication errors and enhancing clinical outcomes

18. National Transitions of Care Coalition
NTOCC Resources:
Taking Care of My Health Care (consumer tool)
Patient Bill of Rights During Transitions of Care
My Medicine List
Transitions of Care Checklist
Transitions of Care Measures
Improving Transitions with Health IT
Issue Brief: Improving Transitions of Care
Medication Reconciliation Essential Data Specifications
Informational Brochure/Slide Deck
Resources available at:

19. Technology Electronic Medical Records
Development has a distinct effect on Transition of Care, helping to overcome one of the greatest hurdles in the transition of care: information exchange between providers
Continued development and universal access to eMR will increase patient safety and yield better outcomes
CMS provides financial incentives through Meaningful Use certification of eMRs to improve quality, safety, efficiency & care coordination

20. Transition of Care Measures
Inclusion of Transitions of Care measures are becoming more common for nationally recognized quality programs including:
NCQA’s Patient Centered Medical Home (PCMH) Standards & Elements
CMS Meaningful Use Requirements (Core and Menu)
3C: Care Management
3D: Medication Management
Performs medication reconciliation
5B: Referral Tracking and Follow-Up
Exchange key clinical information among providers of care
5C: Coordinate with Facilities and Care Transitions
Provide summary care record for each transition of care or referral

21. Resources National Committee for Quality Assurance www.ncqa.org
National Transitions of Care Coalition
Center for Medicare and Medicaid Services
Partnership for Patients
Transitional Care Model
The Care Transitions Program

22. Thank you to AMCP member Tracy McDowd for updating this presentation for 2015