care-transition-coordination

Care Transition Coordination

Manage care transitions between settings including discharge planning, medication reconciliation, follow-up scheduling, and post-acute care coordination.

Overview

This skill enables effective coordination of care transitions across healthcare settings. It encompasses discharge planning, medication reconciliation, follow-up coordination, and communication to ensure safe and effective care continuity.

Capabilities

Discharge Planning

• Assess patient needs
• Coordinate services
• Arrange equipment
• Plan follow-up care
• Educate patients/families

Medication Reconciliation

• Review medication lists
• Identify discrepancies
• Resolve conflicts
• Update records
• Educate patients

Follow-Up Coordination

• Schedule appointments
• Arrange transportation
• Coordinate referrals
• Track completion
• Manage barriers

Post-Acute Coordination

• Assess placement needs
• Coordinate with facilities
• Transfer information
• Monitor transitions
• Address issues

Usage Guidelines

Transition Process

1. Identify transition needs early
2. Assess patient/family situation
3. Develop transition plan
4. Coordinate necessary services
5. Reconcile medications
6. Provide education
7. Execute transition
8. Follow up

Communication Standards

• Timely information transfer
• Complete documentation
• Clear handoff communication
• Patient education materials
• Provider notifications

Risk Mitigation

• Identify high-risk patients
• Address social determinants
• Ensure medication safety
• Verify follow-up completion
• Monitor for readmissions

Integration Points

Related Processes

• Discharge Planning Process
• Care Coordination Protocol
• Population Health Management Program

Collaborating Skills

• clinical-workflow-analysis
• population-health-stratification
• health-data-integration

References

• CMS discharge planning requirements
• AHRQ care transitions resources
• Coleman Care Transitions Model
• BOOST program