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Transitional Care Initiative

Transitional Care Initiative

There is increasing national awareness of medical errors and quality deficiencies that occur during transitions in care. Transition takes place from hospital to home or other interim medical or rehab facility. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is one nationally-recognized organization that has increased its focus on coordination of care after hospitalization. The Institute of Medicine (IOM) is also addressing strategies that may improve outcomes for patients as they transition from one setting to another, and advocates health care models that are patient-centric and collaborative. Our goal with implementation of a transitional support process is to focus on patients' safety and improved quality of care as they move between care settings.

Many of our patients with chronic illness(es) often require care from a variety of providers in multiple settings. Our Transitional Care nurse care managers help patients transition from an inpatient setting to home or to an intermediate care or rehabilitation facility.

Based on other successful Care Transitions models, our network focuses on the Aged, Blind, and Disabled (ABD) and chronically ill patients with complex care needs who meet program screening criteria for intensive Chronic Care Management services. Our Transitional Care case managers use a Standardized Care Management process to provide critical interventions that empower the patient/caregiver with self-management skills. Our ultimate goal for all our transitional patients is to promote better health outcomes for our patients and to decrease utilization of inpatient and emergency department services through focused Care Management interventions.


The Transitional Care process includes:

1. Face-to-face contact with the patient during inpatient admission: We strive to meet and establish rapport with the patient during their admission and assist with the discharge planning process by ensuring that ordered treatments are communicated to providers who will care for the patient after discharge.
2. Medication reconciliation: Probably the most critical component of ensuring a safe transition, our Care Managers are tasked with engaging the patient/caregiver during a home visit or similar face-to-face encounter within 3 days of discharge. The main objective for this contact is to reconcile discharge medication orders with medications ordered by the patient’s primary care provider (PCP), specialists, and with the medications the patient is actually taking in the home setting.
3. Patient self-management and education: This is achieved through patient education that revolves around realistic goals set by the patient and by encouraging the patient and/or caregiver to be an active participant in maintaining their health. CCNC has developed a Self-Management Notebook (SMN) to facilitate communication between the patient and their healthcare providers and to assist in continuity of care across provider settings. Another primary goal of education is to ensure that the patient understands “red flag” symptoms to monitor, what to do if they occur, and when the PCP should be called.
4. Facilitating appropriate follow-up care: One of the primary goals of this transitional component is to encourage the patient to keep all follow-up appointments and to re-link the patient with their PCP after a hospital discharge.