By Toni Cesta, PhD, RN, FAAN


Care transitions has become a buzzword in healthcare. In fact, it has become an important component of case management models and the role of the case manager. This month, we will discuss what transitions in care actually means, particularly as it relates to case management. We will discuss the ever-evolving role of the case manager, both within the hospital and in the community, and how transitions are a strategy for managing cost, readmissions, and patient satisfaction.

In these times of fixed payments and increased finanical risk, whether they are the result of prospective payment systems, managed care reimbursement systems, bundled payment methods, or value-based purchasing, healthcare organizations no longer can afford to keep patients at one level of care for an extended period of time — especially one that is of high acuity, intensity, and cost. Without ongoing assessment for timely transfer to a more appropriate level of care, these organizations risk either no reimbursement for services rendered or denial of payments for all, or a portion of, these services. Transitional planning, traditionally known as discharge planning, is the process case managers apply daily, in conjunction with utilization and clinical care management. This process ensures that the interdisciplinary healthcare team provides patients with appropriate services in the most appropriate setting (i.e., level of care) as delineated in the standards and guidelines of regulatory and accreditation agencies (federal and private).

Transitional planning places the case manager in a pivotal position in the patient care delivery process to ensure quality, safe, efficient, cost-effective, fair, equitable, patient-focused, and continuous care. Transitional planning is defined as a dynamic, interactive, collaborative, and interdisciplinary process of assessment and evaluation of the healthcare needs of patients and their families or caregivers during and after a phase/episode of illness. Transitional planning also includes planning and brokering of necessary services and resources (e.g., durable medical equipment) identified based on the patient’s condition. In addition, it ensures that these services are delivered in the patient’s next level of care (i.e., setting) or after discharge from a hospital. This process is systematic and aims to facilitate the transition of patients from one level of care to another more appropriate, necessary, and reimbursable level without compromising the quality and continuity of care, or the services being provided. (For examples of transitions of care models, see chart in this issue.)

The Continuum of Care

Also known as patient flow, care transitions occur when patients move from one care setting or provider to another care setting or provider. Typically, these transitions occur when patients move across the continuum of care, so let’s start by describing that continuum. One way of looking at the continuum of care is by thinking of it as an endless circle with no beginning and no end. Within that circle are all types of services and locations of those services that our patients might receive over the course of their lifetimes. It covers all phases of illness, from diagnosis to the end of life. It also covers patients who are healthy as they receive primary and preventive care services.

In case management, we often think of the acute care setting as the center of the universe. However, when thinking about patients and the continuum of care it is important to remember that the majority of our patients live in their homes in the community. During their lifetimes, patients may access a wide range of services, from home health to hospitalization to primary care. Care providers may change during each of these episodes. It is during these periods of transition that things may fall through the cracks, leading to overuse of healthcare resources, lack of coordination and communication, and poor outcomes for patients. For these reasons, transitions have become an important tool in the case manager’s toolkit.

When thinking about transitions in care, consider the level that the patient is currently in and the levels to which he or she must move. These levels include the following:

• Preacute services are those offered to prevent illness or deterioration/changes in the patient’s health condition that may require acute care or hospitalization. Examples of these services are health risk assessment and screening (e.g., cholesterol and blood pressure/hypertension screening, mammography, prostate screening, risk assessment questionnaires focusing on degree of healthy lifestyle), patient and family education materials for wellness, health promotion and illness prevention, health advice lines, triage services, and counseling. Settings included in these types of services are managed care organizations, ambulatory/clinics, physician offices or group practices, and community-based health centers.

• Acute services are those provided during an acute episode of illness and in a hospital setting. Examples include emergency and trauma care, and procedures such as coronary artery bypass graft. Settings include hospitals, acute rehabilitation facilities, postanesthesia units and ICUs, and EDs.

• Post-acute services are those provided for patients after an acute episode of care, whether in a facility setting or at home. These services typically include rehabilitation and health maintenance. Examples include subacute care, geriatric rehabilitation services, skilled care, and home care services. Settings include long-term care facilities, skilled nursing facilities, assisted living, palliative and hospice care, and home care agencies.

Case managers often are the link that provides consistency for our patients during these periods of transition. By providing that link, case managers help to guide and track patients over time through a comprehensive array of healthcare services spanning all levels of care.

Healthcare is in its infancy in terms of creating truly integrated systems that link patients across the continuum. While we are moving toward bundled payments, we are still receiving payment based on volume, procedures performed, and episodic care. In order to truly evolve toward population management, care must be much more coordinated across the continuum with the patient at the center of the hub, rather than the care provider or setting. For this infrastructure to exist, there are a variety of components that must be in place. These components include the following:

  • integrated medical records;
  • integrated IT solutions;
  • telehealth services;
  • preventive care;
  • chronic disease management;
  • high-risk community-based case management;
  • transitional care coordination;
  • case management;
  • extended accessibility.

Accountable care organizations (ACOs) are designed to provide an infrastructure that combines each of these components. Even if your organization does not contain an ACO, it still will be necessary to perform like one in order to remain competitive in an era of bundled payments and value-based purchasing.

Case Management and Integrated Care

Integrated care is a concept bringing together inputs, delivery, management, and organization of services related to diagnosis, treatment, care, rehabilitation, and health promotion. Integration is a means to improve services in terms of access, quality, user satisfaction, and efficiency. Integrated healthcare, often referred to as interdisciplinary healthcare, is an approach characterized by a high degree of collaboration and communication among health professionals. What makes integrated healthcare unique is the sharing of information among team members related to patient care and the establishment of a comprehensive treatment plan to address the biological, psychological, and social needs of the patient. The interdisciplinary healthcare team includes a diverse group of members (e.g., physicians, psychologists, RN case managers, social workers, and occupational and physical therapists), depending on the patient’s needs.

The benefits of an integrated healthcare approach extend to patients, caregivers, providers, and the larger healthcare system. For instance, research indicates that integrated healthcare is effective in reducing readmissions and unnecessary admissions. Further evidence suggests that coordinated care, which integrates psychologists and other mental health providers within primary care, can enhance access to services, improve quality of care, and lower overall healthcare costs across the continuum. It is clear that in order to positively affect clinical outcomes, patients’ behavioral health and psychosocial needs must also be addressed. An integrated approach between RN case managers and social work case managers is one of the many effective strategies that must be incorporated into any program.

Case management can be thought of as the glue that holds the continuum of care together. Integrated care cannot occur without it. Therefore, case managers must be assigned at all transition points across the continuum. By ensuring that case management is available at all transition points, we can better ensure that case managers link all healthcare settings and providers. Case managers provide the infrastructure for the coordination and integration of these services.

A key element in managing care transitions is the process of transitional planning. This creates the foundation for an integrated system. Transitional planning can be thought of as a process to facilitate movement of a patient from one care setting to the next, or from one care provider to the next. Effective transitions are the core business of a contemporary case management department as well as a core responsibility.

The transitional planning process helps healthcare organizations implement the care plan and prevents unnecessary duplication of services. It consists of the following seven steps or phases in patient care:

  1. assessment of the patient’s condition, risks, and needs;
  2. development of the discharge/transitional plan, including the goals of treatment and disposition;
  3. implementation of the plan;
  4. evaluation, ongoing monitoring, and modification of the plan as warranted;
  5. confirmation of and final preparation for the patient’s discharge or transition;
  6. discharge or transition of the patient to another level of care or to home;
  7. follow-up communication with patient post-discharge.

When incorporating your department’s transitional processes, the first point to consider is the creation of an “across the continuum” transitional planning process. The planning process must include both the sender of the patient as well as the receiver of the patient.

There are a number of care transition models developed over the past several years to improve quality of care, ensure safe patient transitions, and maximize cost-effectiveness while reducing financial and reimbursement risks. Case management programs that do not include a special focus on transitions of care using the evidence these models demonstrated are considered outdated.

Examples of care transition models can be found in the table in this issue.


Regardless of the transitional care model or discharge/transitional planning process and tools an organization uses, effectiveness depends on improving the decision-making process to determine the best next level or care setting for the patient, and safe patient transitions. Case managers must incorporate these practices into their daily routines to meet patient and organizational outcomes.

Transitions of Care Models

Care Transitions Intervention (CTI)

Coleman CTI model

  • A four-week program designed to foster patient engagement and promote safe transitions from the hospital or skilled nursing facility to home.
  • Decreases rehospitalizations.
  • Four pillars for safe transitions: medication self-management; maintenance of a personal health record; primary care provider follow-up; alertness to red flags (e.g., management of symptoms or situations of concern).
  • Uses a transition coach for the patient. The coach focuses on the patient’s self-identified goals and helps the patient develop comfort with self-care management and engagement in taking care of own his or her own health.
  • Coach does not assume home care or case management responsibilities.
  • Coach initiates contact while patient is in the hospital, obtains patient’s consent to participate, and completes a home visit 72 hours post-discharge.
  • Three phone calls completed after the home visit that focus on follow-up care with primary care provider, medications, and other support services.

Transitional Care Model (TCM)

  • Involves 1-3-month period of interventions to prevent rehospitalizations.
  • Focuses on high-risk older adults with specific risk factors including cognitive impairment and any of the following: 80 years or older; functional deficits; active psychiatric condition; four or more comorbidities; six or more prescribed medications; two or more hospitalizations in past six months; inadequate social support system; poor health literacy; poor adherence to medical regimen.
  • Employs the role of advanced practice registered nurse (APRN).
  • Starts in the hospital setting where a specialized APRN completes a patient assessment and collaborates with the healthcare team in the development of an effective transitional plan.
  • APRN visits patients after discharge from the hospital, reaches out to the patients by phone, and follows up on post-discharge care; accompanies patients on first visit to primary care provider post-discharge; communciates with the primary care provider and ensures important information has been exchanged; assists patients in identifying early signs and symptoms of worsening condition.
  • Model relies on patient engagement, goal-setting, and communication with patient, family, and members of healthcare team.

Better Outcomes for Older Adults through Safe Transitions (BOOST)

Society of Hospital Medicine

  • Focuses on hospital discharge process and communication with patients and receiving providers.
  • Enhances quality of transitions and offers tools for the standardization of transional care.
  • The Eight Ps for risk assessment: Polypharmacy; Psychological comorbidities; Principal diagnosis of cancer, stroke, diabetes, chronic obstructive pulmonary disease, or heart failure; Physical functional limitations; Poor health literacy; Poor social support system; Prior hospitalization in the six months before index period; Palliative care needs.
  • Involves discharge planning, medication reconciliation, patient and family communication, discharge instructions, and communication with patient’s primary care provider before discharge.
  • Facilitates scheduling of patient’s follow-up care appointment and includes post-discharge telephone call to patient.
  • Uses teach-back method in patient education and discharge instructions.

Project RED (Re-Engineered Discharge)

Boston University Medical Center

  • Improves hospital discharge process, promotes patient safety, reduces rehospitalizations, and enhances patient’s experience with care.
  • 12 interventions: language assistance; scheduling appointments for follow-up care and testing; follow-up on pending test results post-discharge; organization of post-discharge services and equipment; medication education and planning to ensure access to medications; development of discharge plans based on national guidelines; patient understanding of discharge plan; patient education regarding diagnosis; what to do in case of post-discharge problems; sharing of discharge summary of care with providers following up on the patient; post-discharge telephone follow-up on patient.

Interventions to Reduce Acute Care Transfers (INTERACT)

Developed by group of experts, supported by a grant from the Commonwealth Fund, located at Florida State University.

  • Improves care in the long-term care setting (LTC), skilled nursing facilities (SNFs), and assisted living facilities (ALFs).
  • Reduces preventable hospital readmissions.
  • Includes a number of quality improvement strategies for the management of changing patient’s condition in these settings.
  • Offers tools to help healthcare professionals document, communciate and institute early interventions to avoid worsening of patient’s condition and hospitalizations.
  • Enhances communciation among providers in the LTCs, SNFs, ALFs and hospitals.