Transitions of care

CCMC Glossary of Terms Related to Transitions of Care

Transitional Planning: The process case managers apply to ensure that appropriate resources and services are provided to patients and that these services are provided in the most appropriate setting or level of care as delineated in the standards and guidelines of regulatory and accreditation agencies. It focuses on moving a patient from most complex to less complex care setting.

The Case Managers Role in Transitions of Care

Transitions of care can occur within a facility, when a patient is transferred from the ICU to the step down unit, between facilities such as from a hospital to a Skilled Nursing Facility, and within the community from the Primary Care Physician to the Specialist.  On CMS website they define transition of care as the movement of a patient from one setting of care (hospital, primary care practice, specialty practice, long-term care, home health, rehabilitation facility) to another. 

A patient transitioning between providers is at increased risk for an adverse outcome. This can be due to medication errors, failure to follow up on testing or procedures or not continuing prescribed treatments or therapies. Most of these are related to communication breakdown. For this reason CMS recommends providers provide a summary of care for all transitions of care or referrals. Another issue is accountability, identifying who is responsible for what. 

The Case Manager is often involved during all points of transition and in contact with the patient, family and providers. This makes them best suited to serve as coordinator of transitions of care.