The Centers for Medicare & Medicaid Services (CMS) defines a transition of care as the movement of a patient from one setting of care to another. Settings of care may include hospitals, ambulatory primary care practices, ambulatory specialty care practices, long-term care facilities, home health, and rehabilitation facilities. Transitions increase the risk of adverse events due to the potential for miscommunication as responsibility is given to new parties. Hospital discharge is a complex process representing a time of significant vulnerability for patients. Safe and effective transfer of responsibility for a patient’s medical care relies on effective provider communication with patient comprehension of discharge instructions. (AHRQ Care Coordination Chartbook)
This page will provide information and outputs of the MBQIP 2 Outcomes Care Transitions Project (2020); as well as additional resources to assist CAHs in building strong Transitions of Care programs.