Transitional Care Management

What is Transition of Care Management?

Transitions of Care refer to the movement of patients between health care locations, providers, or different levels of care within the same location as their conditions and care needs to change.

Key Elements

Discharge planning
Medication reconciliation
Timely provider access
Timely post-discharge follow up visit
Facility access to care and services needed

Goals

Improve individual/family/caregiver’s participation in healthcare decisions and management
Improve ability to self-manage health conditions, medication adherence and participation in health promotion activities
Assist in proactive monitoring, evaluation, and problem solving
Improve collaboration among and between individual/family/caregiver providers
Improve the coordination and continuity of care across the continuum of care
Improve individuals/family/caregiver’s health status, satisfaction and quality of life.
Improve the delivery of cost effective care in the least restrictive environment