LONGITUDINAL:
STANDARDS OF
PRACTICE
CONSENSUS
MEASURES
EFFECTIVE
TRANSITIONS OF CARE
An ACMA collaboration representing the healthcare continuum.
Expertise
National Executive Steering Committee
representing 10 practice settings.
Standards
Longitudinal Standards for effective
patient’s Transitions of Care.
Implementation
A model framework to facilitate meaningful
implementation and measure performance.
Thought Leadership
ACMA included representation from 15
organizations representing 10 practice
settings that influence navigation of our
healthcare system.
Transitions of Care Standards
The American Case Management Association established national standards of practice for case management, and now broadens its scope to include the development of Transitions of Care (TOC) Standards.
The phrase Transitions of Care (TOC) describes a process of transferring a patient’s care from one setting or level of care to another, such as from hospital to home or hospital to skilled nursing facility. These transitions are particularly vulnerable points in the healthcare continuum.
The ACMA TOC Standards provide a framework – applicable across all care settings – to implement and evaluate a process to improve care transitions.
$26
BILLIONS
Spent on poor transitions of
acute care Medicare patients per
year.
Standard 1.0
Identify patients at
risk for poor
transitions
Standard 2.0
Complete a comprehensive assessment
Standard 3.0
Perform and
communicate a
medication
reconciliation
Standard 4.0
Establish a dynamic
care management
plan that addresses
all settings
throughout the
continuum of care
Standard 5.0
Communicate
essential care
transition
information to key
stakeholders across
the continuum of
care
Implementation
Using these standards can help:
- Patient engagement
- Improve patient experience
- Decrease readmission and Emergency Department utilization
- Medication safety
- Physician satisfaction
- Advance care planning improvements