Establish standard operations to manage transitions of care that could include one or more of the following:
- Establish formalized lines of communication with local settings in which empaneled patients receive care to ensure documented flow of information and seamless transitions in care; and/or
- Partner with community or hospital-based transitional care services.
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Enhance communication during care transitions to improve patient outcomes by establishing standard operations, or preferred practice patterns, for transition communications.
Evidence of information flow during transitions of care. Include at least one of the following elements:
- Communication lines with local settings – Documentation of standardized lines of communication to manage transitions of care between settings. Communication can occur in whatever format is most useful based on the circumstances of the eligible clinicians; OR
- Partnership with community or hospital-based transitional care services – Documentation showing partnership with community or hospital-based transitional care services (e.g., written agreement, workflow documentation).
- A busy hospitalist group in a community hospital has heard complaints from eligible out-patient care primary care clinicians, who report that they are following up on discharged patients without understanding the details of the admission or the changes in medications made. To address this complaint, the hospitalist group creates an electronic health record-based system by which a discharge summary is completed within 24 hours of discharge and which is automatically sent to the patient’s eligible primary care clinician (email, fax, etc.). The summary includes medication reconciliation information.
- Emergency departments see many patients with chest pain daily. An emergency department (ED) eligible clinician group meets with the cardiology eligible clinician group to arrange for immediate follow-up on moderate-risk chest pain patients after patients have been cleared for discharge by the ED. A telephone conversation occurs between the eligible ED clinician and the eligible cardiologist for every discharged patient who will be seen within 24 hours for evaluation and exercise stress test.