The National Transitions of Care Coalition (NTOCC) uses seven key elements that help health systems adopt value-based care. The NTOCC’s care transition bundle essential intervention includes the following categories:

• Medication management. “Case managers have a role in better medication management and medication reconciliation,” says Cheri Lattimer, RN, BSN, executive director of NTOCC in Prescott, AZ. “Case managers over these last 10 years have been coached to ask patients medication questions.”

These questions include:

- What do you have in your medicine cabinet at home?

- What drugs are you buying over the counter?

- Are you taking any natural health supplements on top of that?

- Do you buy any medication through mail order?

- If you live in a border town, do you cross the border to pharmacies to get medication?

Case managers also can ask tough questions about patients’ substance abuse and pain medications, she adds.

Much of this medication management can be accomplished through these types of questions, but the optimal strategy is a home visit. “With geriatric patients, it’s not unusual to find medications that have not been reported by the patient but are in the home,” Lattimer says.

“Someone visiting the home might find the patient is already on a beta-blocker that was not documented,” she adds.

Medication management and reconciliation are low-hanging fruit, and case managers are well suited to assist, Lattimer says.

• Transition planning. The goal is excellent follow-up care from one transition to the next.

“Professional case managers in the hospital should ensure that wherever the patient is going, from whatever care, they can make sure information is transferred from the next case manager in that area,” Lattimer says.

“You don’t have to own everything, but you do have to be accountable to share information with the next level of care for continuity of care,” she adds. “If the hospital patient needs follow-up, then make that follow-up call.”

In advanced accountable care organizations, care coordination is successful when case managers help coordinate patients’ transition to the next level of care.

“It comes back to communication and good care coordination,” Lattimer says. “One does not occur without the other; those two are key.”

• Patient and family education and engagement. Focus on patient and caregiver education and shared decision-making, Lattimer advises.

“Just writing out a transition plan with instructions and handing it to the patient is not shared decision-making,” she says. “Case managers should take time to sit down and go over information even before the plan is complete, and ask the patient and caregiver if the information makes sense and if they are able to follow the instructions.”

When creating a plan, case managers help patients eliminate obstacles to fulfilling the plan. If there is a follow-up doctor’s visit in four days, then the case manager might ensure the patient has transportation to get to that appointment, Lattimer says.

“Make sure you agree on a plan,” she says.

For instance, if the patient is seriously ill and must decide on the next course of treatment, the case manager can help the patient share his or her treatment preferences.

“If we just write a prescription for the patient and that treatment is not in the patient’s mindset, then we’ll soon have the patient back in the hospital,” she explains.

Without obtaining the patient’s engagement and agreement, the patient may not comply.

“We have to make sure — before we send them home — that they have agreed to follow through with the treatment plan,” Lattimer says. “Sometimes, these plans fall apart when the patient gets home because we talk to patients when they’re in a hospital bed and they may not always understand us.”

• Information transfer. Information about the patient’s health and care should be shared among the patient, caregiver, and healthcare providers as timely and effectively as possible.

Health systems need electronic health records and should be able to share medical information between providers. For example, a health system can use a transfer tool, transition record, transition summary, or a web-based care management tracking tool, according to NTOCC’s care transition bundle. (Read more about the transition bundle at:

But electronic records and coordination tools are not always enough to ensure efficient information transfer. Health systems also need to make sure their electronic records can capture critical case management information related to care coordination.

“Often times, case managers’ assessment notes in support of patients’ preferences is hard to find in electronic health records,” Lattimer says.

Without ready access to information about patients’ preferences and access obstacles, healthcare providers will lack necessary information for a successful transition.

“The professional case manager takes time to collect all of this information and communicates it, but if it’s not clearly available in the electronic health record, then we’ve lost an important part of the documentation,” Lattimer says.

“Communication is the most important piece of care coordination,” she adds. “We can use all the tools and checklists, but if we’re not coordinating this from one level of care to the next and communicating this clearly, then we’re losing ground.”

If providers do not receive information on the patient’s care plan and repeat what case managers have already said, patients might stop talking and become disengaged.

“If we ask the same questions over and over and we’re not documenting it or looking at it in advance, then patients might say, ‘I’ve given this information before, and I’m not going to do it again,’” Lattimer says.

• Follow-up care. “I think 80% of the time a patient and caregiver will get home and within 24 hours they will say, ‘What did that nurse say, or the doctor says I’m supposed to do what?’” Lattimer says.

Effective transition planning depends on thorough assessments, documentation, and communication. But it also depends on case managers following up to ensure patients know what to do once they leave the hospital and are able to take the next steps in their medical care.

“Once a patient has left the hospital that follow-up call might be the next [healthcare contact] they have,” Lattimer says.

Case managers also can confirm patients’ physician follow-ups and make appointments for post-discharge testing. They can arrange for provider home visits soon after discharge. They also might call patients to reinforce the transition plan and see whether patients have any issues that should be resolved, according to NTOCC’s care transition bundle.

For instance, case managers can help patients connect with area nonprofits that provide meals and other services if patients have trouble with activities of daily living on their own.

• Healthcare provider engagement. Every provider involved in a patient’s care and transition should know what is going on, and it often is case managers’ responsibility to share information and increase engagement, Lattimer says.

The case manager’s role also includes improving documentation around the patient’s condition, making sure providers in the hospital and in the community have access to information about the patient’s hospital and/or ED admission, reconciling medication lists, and essentially serving as a communication hub, according to NTOCC.

Patients should be coached on self-care management and how to identify signs of medical problems.

• Shared accountability across providers and organizations. Physicians do not shoulder the entire responsibility. There is shared provider accountability, and this includes the clinical care team and case management team, Lattimer notes.

The patient’s plan of care should be communicated clearly and timely to patients and providers on the care continuum, the NTOCC care transition bundle states.

The key in transition planning is a thorough assessment by the professional case manager, sharing the assessment with all involved providers and with the patient and caregiver, Lattimer says.

All of those involved must interact with each other, document all actions taken, and put the care plan in place to meet the patient’s and caregiver’s needs after the patient has left the hospital, she adds.

“The case manager has the role of assisting with core communication,” she says.