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Seven steps for managing transitions of care

Effective care transition management is a key to achieving value-based care for your patients


While it is easy to feel powerless during care transitions and difficult to influence the processes and handoffs taking place outside your practice’s walls, don’t despair: You can build a rigorous transition of care process that can make a difference in how your practice operates.

Ideally, a care transition is a value-based, patient-centric event that does not disrupt the continuity of care.


Unfortunately, the process of moving patients from one setting to another, or transferring their care between providers, is an uncertain process. All too often delays, disruptions, and miscommunications lead to confusion, unnecessary costs and care, and, ultimately a great deal of frustration for patients and physicians alike.

The most frequent pitfalls in the transition process are:

  • poor communication between facilities and providers;
  • insufficient engagement in the transition process by patients and caregivers; and
  • failure by the local medical community to demand and clearly designate strict accountability for managing the transition. 

Here are steps your practice can take to improve care transitions for your patients.

1. Formalize your inbound patient referral process

Your electronic health record (EHR) may have tools to help communicate information you want to know about a new or referred patient, but don’t expect any system to perform the whole job by itself.

List the information you need to manage the care of patients you accept from other providers. If your EHR doesn’t provide an electronic consult request form, create one. Make sure that the form is in a format the transferring facility or provider can easily view, such as a text file or Excel spreadsheet. Even a hard copy printout will work. Design it in the form of a checklist of all critical elements—patient history, records, medications, and other information—that you want on hand either before or during the patient’s visit. If you want patients or referring providers to send more information, make sure to also tell them when you need the data.

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