Clinical Basis

Transition of care is defined as any time a member is discharged from a hospital or nursing home. Four best practices have been identified to ensure best outcomes for these members during the transition to ambulator setting:

1. Process to be notified of all inpatient admissions.
2. Receipt of discharge information within 2 days
3. Patient engagement after discharge within 30 days
4. Medication Reconciliation within 30 days

Transitions of care have consistently been shown to be a high-risk time period for poor clinical outcomes. Through a focus on 4 critical practices outlined above the intention is to deliver a better experience and improved outcomes for members.

Group Best Practices

Transitions of Care and Plan All Cause Readmission are two measures that support one another.¹ Ensure patients receive discharge instructions in a timely manner and schedule an appointment with patients within 7 days of discharge to review discharge instructions and develop a care plan.