Transitions of Care & Readmissions

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)


Tools & Resources for Successful Care Transitions

CMS Care Compare

Recent Conditions of Participation for Discharge Planning include a requirement to use and share data to assist in selecting post-acute providers. Data must be relevant and applicable to patient’s goals of care and treatment preferences.

All CMS “Compare” sites were grouped under Care Compare as of 12/1/2020.

Montana Community Resources

Communicating resources for patients that address social, behavioral and other needs is vital to prevent readmissions and give the patient complete, holistic care.

Assessing the patient social and behavioral health needs is an integral part of a careful discharge and may help prevent potential readmissions. Montana hospitals can use the resources here to build a their own community resource guides.