This page is part of the PACIO Transitions of Care Implementation Guide (v1.0.0-ballot: STU 1 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. No current official version has been published yet. For a full list of available versions, see the Directory of published versions

General Guidance

Page standards status: Informative

This section provides additional guidance on the relationship between the associated profiles and the structure of the interoperable transitions of care document.

Purpose of Defining Transitions of Care Data Elements

Post-acute care transitions of care are critical for ensuring continuity, safety, and quality of care as patients move from one healthcare setting to another, such as from a hospital to a skilled nursing facility, home health care, or rehabilitation center. Effective transitions reduce the risk of adverse events, rehospitalizations, and gaps in care. Below are the important aspects of post-acute care transitions:

Comprehensive Discharge Planning

Discharge planning is essential to ensure that patients leave the acute care setting with a clear plan for managing their health. This includes medication reconciliation, follow-up appointments, and instructions for self-care.

• Evidence: A systematic review by Hansen et al. (2011) found that comprehensive discharge planning and follow-up interventions significantly reduced hospital readmissions. (Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Ann Intern Med. 2011;155(8):520-528.)

Effective Communication Between Providers

Clear communication between healthcare providers across settings (e.g., hospital to skilled nursing facility) is critical to avoid information gaps that can lead to errors or delays in care.

• Evidence: Kripalani et al. (2007) emphasized that communication failures during transitions are a major contributor to adverse events. Structured communication tools, such as discharge summaries and standardized handoff protocols, improve outcomes. (Kripalani S, Jackson AT, Schnipper JL, Coleman EA. JAMA. 2007;297(8):831-841.)

Medication Reconciliation

Ensuring accurate medication lists and reconciling changes made during hospitalization is vital to prevent medication errors, which are common during transitions.

• Evidence: A study by Coleman et al. (2005) highlighted that medication discrepancies during transitions are associated with adverse drug events. Implementing medication reconciliation processes reduces these risks. (Coleman EA, Smith JD, Raha D, Min SJ. Arch Intern Med. 2005;165(16):1842-1847.)

Patient and Caregiver Education

Patients and their caregivers must understand the care plan, including medications, follow-up care, warning signs, and how to access resources. Education empowers patients to manage their health effectively.

• Evidence: Research by Naylor et al. (1999) demonstrated that patient-centered education and support during transitions improve outcomes and reduce rehospitalizations. (Naylor MD, Brooten D, Campbell R, et al. JAMA. 1999;281(7):613-620.)

Follow-Up Care Coordination

Timely follow-up appointments with primary care providers or specialists are crucial to monitor progress, address complications, and reinforce the care plan.

• Evidence: The Care Transitions Intervention (CTI) model developed by Coleman et al. (2006) showed that structured follow-up care significantly reduced 30-day readmissions. (Coleman EA, Parry C, Chalmers S, Min SJ. Arch Intern Med. 2006;166(17):1822-1828.)

Use of Transitional Care Models

Evidence-based transitional care models, such as the Transitional Care Model (TCM) or Project RED (Re-Engineered Discharge), provide structured approaches to improving care transitions.

• Evidence: The Transitional Care Model (TCM), developed by Naylor et al., has been shown to improve outcomes for older adults with complex care needs during transitions. (Naylor MD, Aiken LH, Kurtzman ET, et al. Health Aff (Millwood). 2011;30(4):746-754.)

Addressing Social Determinants of Health

Social determinants such as transportation, housing, and access to food can impact a patient’s ability to adhere to the care plan. Identifying and addressing these factors is essential.

• Evidence: Studies have shown that addressing social determinants improves patient outcomes and reduces readmissions. For example, Berkowitz et al. (2018) found that interventions targeting food insecurity reduced healthcare utilization. (Berkowitz SA, Hulberg AC, Standish S, et al. Health Aff (Millwood). 2018;37(3):393-400.)

Use of Technology and Telehealth

Technology, such as electronic health records (EHRs) and telehealth, facilitates communication and monitoring during transitions, especially for patients in remote or underserved areas.

• Evidence: A study by Lin et al. (2020) found that telehealth interventions during care transitions improved patient satisfaction and reduced hospital readmissions. (Lin MH, Yuan WL, Huang TC, et al. J Med Internet Res. 2020;22(10):e19099.)

Monitoring and Quality Improvement

Ongoing evaluation of transition processes, including patient outcomes and satisfaction, allows healthcare organizations to identify gaps and implement improvements.

• Evidence: The National Transitions of Care Coalition (NTCC) emphasizes the importance of monitoring key metrics, such as readmission rates and patient satisfaction, to improve care transitions. (NTCC. Improving Transitions of Care: Findings and Considerations of the "Vision of the National Transitions of Care Coalition." 2008.)

Effective post-acute care transitions require a multidisciplinary approach that emphasizes communication, patient education, medication safety, follow-up care, and addressing social determinants. Evidence-based models and interventions, such as the Transitional Care Model and Care Transitions Intervention, have demonstrated their ability to improve outcomes and reduce rehospitalizations.

By focusing on these key aspects, healthcare providers can ensure smoother transitions, better patient outcomes, and reduced healthcare costs.

Transitions of Care Document Structure

The Transition of Care composition defines 16 sections:

Section	Description
Advance Directives	Examples include Personal Advance Care Plans, Portable Medical Orders, Mental Health Advance Directives, Episodic Advance Directives
Allergies	List of allergies the patient has
Behavioral Health	Examples include assessments, observations, drug education, medication review, self harm, family participation, legal participation
Functional Status	Examples include assessments, mental status, mobility, activities of daily livings, swallowing, devices needed
Immunizations	List of immunizations patient has received and when
Instructions	Narrative instructions and notes
Medication Equipment	List of equipment patient needs to take medications
Medications	List of medications prescribed for the patient. Examples include medications received (administration lists, discharge lists, discontinued lists), high risk drug classes, opioids
Plan of Care	Care plan created for the patient. Care plans can include conditions and their treatment, substance abuse, care management, and nutrition information
Problems	Examples include fever, vomiting, dehydration, internal bleeding, shortness of breath, pain
Procedures	List of procedures the patient has undergone
Reason for Referral	Examples include discharge summary (reason, destination, location, status, setting, admitted from)
Reason for Visit	Examples include referrals from encounters
Results	Examples include lab results
Social History	Examples include medical history, prior level of functioning, substance abuse, ethnicity, race, coverage (Medicare, Medicaid, private, self), transportation, demographics, dental
Vital Signs	Examples include height, weight, blood pressure, oxygen levels