Transitions of Care Toolkit


Welcome to the Transitions of Care Toolkit. The resources in this toolkit are a guide for improving your patients’ health outcomes through more effective care transitions.

We are committed to enhancing your current high-quality processes by providing additional knowledge, tools, and resources for your entire patient population.

The VHAN team is here to help your practice. We encourage you to reference the resources contained in this toolkit and to reach out when you need additional support. You can contact a VHAN team member at

Why Transitions of Care?

Care transitions are the biggest opportunity for breakdowns in care delivery. In our current care environment, significant and unnecessary variations in care are common. The same is true of sub-optimal processes for sharing information across care settings. This leads to adverse patient outcomes and experiences, while undermining providers’ ability to deliver effective care.

In total, it is estimated that inadequate care coordination during care transitions is responsible for somewhere between 25-45 billion in wasteful spending nationally.

A focus on more effective transitions of care can promote continuous improvement opportunities and establish foundational infrastructure to be successful in value-based care, ensuring patients receive the highest quality of care.

  • 50% of hospital-Related medical errors are attributed to poor communication during transitions of care.
  • 57% of providers report that issues fall between the cracks when transferring patients.
  • Chronically ill patients will see an average of 16 physicians per year.

Best Practices for Care Transitions

Use the following best practices as a checklist for improving care transitions for all your patients. These activities should be completed at every transition within a patient’s care journey.

Patient-Centered Approach

Every patient’s healthcare journey is different. Each patient’s experience occurs across a continuum of multiple points of care. Many times, the only constant along the continuum is the patient, who should therefore be regarded as the expert on his or her healthcare journey.

At each stop along their journey, there are opportunities for providers to partner with patients in their care to help guide and support them. 

To improve care transitions across the care continuum, we must foster the concept of the Medical Neighborhood, which is defined by the Patient-Centered Primary Care Collaborative as “a clinical-community partnership that includes the medical and social supports necessary to enhance health, with the Patient-Centered Medical Home serving as the patient’s primary ‘hub’ and coordinator of health care delivery.”

Patient experiences should be treated as a whole, rather than parts and pieces. All transitions are stops along a journey, not separated and isolated episodes. Highly-coordinated care among physicians, nurses, pharmacists, and social workers is required to improve care transitions. 

Key Takeaway:
A patient-centered approach is the first step to positive changes in transitions
of care within your practice.

Patient Care Accountability

Establishing accountability for a patient is the most important piece of the puzzle. It requires close collaboration between patients and providers. To use a sports analogy, the partnership between patient and provider is the same as a quarterback and a coach. The patient plays the role of quarterback, taking ownership of what happens with his or her healthcare experience. The provider serves as a coach, ensuring the patient is fully equipped to succeed.

The Patient Role
As discussed above, the patients are the experts on their own healthcare journeys and experiences. As such, they are responsible for their care in partnership with their providers. As patients transition from one care setting to the next, they play a critical role in ensuring information is shared. To support patients, we encourage using patient/family compacts, which are agreements between providers and patients outlining mutual expectations for information sharing and shared decision making practices.

The Provider Role
Maintaining accountability for a patient’s care across multiple providers and settings is difficult. Often, the provider with primary accountability is defined by payers through attribution logic, defined below. One way to manage this is through the medical neighborhood construct, wherein providers build relationships with other members of the care team and implement care compacts with patients. Please check the VHAN Content Hub ( for examples of care compacts. An accountability mindset means always assuming that other providers involved with a patient’s care don’t have the information required to be successful. Conversely, you should always assume that you also don’t have a full picture of the patient’s health. Be proactive and anticipate issues created by care transitions.

Key Definition:

While each practice should take ownership of their patients’ transitions of care, attribution is a method payers use to identify the provider who is primarily responsible for the care of the patient. A patient is attributed to the provider who defines the care plan of the patient to ensure appropriate accountability for the patient’s outcomes and costs. Attribution logic may vary by payer but traditionally is driven by frequency/utilization of a provider. A patient attribution report is the total panel of patients from a given payer, who are assigned to a specific physician.

Medication Reconciliation

Medication reconciliation is the process of obtaining, verifying, and documenting a patient’s medication list and discussing and resolving discrepancies. Medication reconciliation can decrease medication errors and prevent patient harm across the continuum of care.

Completing a comprehensive medication reconciliation can be very time consuming and challenging due to a lack of access to outside medical records, multiple providers caring for a patient, and patients not providing accurate information about their medications. This is why medication reconciliation should occur at each outpatient encounter and at admission, transfer, and discharge while in a facility.

  • 20%-The average hospitalized patient is subject to at least one medication error per day, about 20 percent of which will result in harm.
  • 40%-40 percent of medication errors are attributed to inadequate handoffs.
  • 72%-72 percent of post-discharge events are related to medication.

The Joint Commission recommends a five-step process for conducting medication reconciliation.

5 Step process

Step no.

step description


Develop and document a comprehensive list of all current medications a patient is taking or should be taking.


Determine new medications to be prescribed.


Compare the new prescriptions with the list developed in Step 1.


Make clinical decisions pertaining to what medications should be continued.


Communicate the new medication information highlighting any medicines that
were added, stopped, or changed to patient and patient’s caregivers.


Best Practice:
Have patients bring in all medications to help create a comprehensive and accurate medication list. You can also obtain pharmacy fill information by contacting the patient’s retail pharmacy.

Patient and Family Engagement

If you can’t effectively engage patients and families in the coordination of their care, it’s like sending the team out to play without a quarterback. You need the patient’s partnership to drive positive outcomes.

A big piece of engaging patients and their families is addressing health literacy, which is the degree to which a person can comprehend and make informed health choices. Research shows that 9 out of 10 people have difficulty understanding and using routine health information.

This is a real challenge because patients with low health literacy:

  • Are more likely to visit an emergency room
  • Have more hospital stays
  • Are less likely to follow treatment plans
  • Have higher mortality rates

One way to address low health literacy is through teach-back strategies, which involve asking the patient to repeat instructions and action steps. Specific opportunities for this approach include:

  • Changes to the care plan
  • Self-management instructions
  • Warning signs and how to respond
  • Guidance for emergency and non-emergency after-hours care

One way to effectively address health literacy and engage the patient/family in a shared decision making process is to follow the AHRQ’s SHARE method.

Quick Tip:

Simple adjustments to patient visits can create big opportunities for increased engagement. Use clear, easy-to-understand words. Research shows that if a provider sits during a patient visit instead of standing, patients perceive more time is being spent with them. This also models to the patient that you are actively listening and engaged in the care process.


Transition documentation should be clear, concise and direct. This documentation should
be shared with all appropriate providers in a timely way,  ideally within 24-48 hours after
a transition.

Standard communication elements should include each of the following:

  • Medication list with timing and dosing and reason for taking each medication, highlighting changes
  • Any recent lab/imaging results/findings, or new diagnosis
  • Orders to include labs, imaging, treatment, services, and/or equipment
  • Action items for the receiving provider including expected timelines, key milestones, and escalation plans
  • Key findings from anciliary consults (i.e. Psych, SLT, PT, OT, SW, RT, RD, Pharm)

Key Question:
Have you recently reviewed your current transition documentation? Standard EMR- generated transition or referral documentation does not consistently include all of the most relevant and important information needed to manage transitions of care. VHAN’s population health associates can review your processes and transition documentation to make sure all key information is included. Email for assistance.

Warm Hand Offs

Patient care needs can be very complex, requiring additional communication to ensure receiving providers are well prepared for assuming the responsibility of care. There should be a warm hand off in the form of a clinician-to-clinician direct communication to allow for questions, clarifications, and sharing of potentially sensitive information that may not be contained within an EMR or transition document.

  • Make a warm hand off to accountable person(s) at the next care site.
  • Identify the next transition site and responsible healthcare professionals (PCP, nurses, site staff).
  • Report current patient status.
  • Set a goal of scheduling and completing at least 80 percent of next site encounters.

Important Note:
This hand off must consist of a direct and personalized communication from clinician to clinician. Many times faxes or EMR notes never reach the next provider.

Community Engagement

To effectively care for patients, providers must strive to check that their basic needs are met. A patient’s socio-economic status, home environment, and psychological wellness can significantly affect overall health and well-being.

Did You Know?
Your VHAN Care Management team can help you identify and access community resources for your patients. Call (615) 936-2828 or email

Qpplying the Transitions Checklist

For Primary Care Providers:

Patient Care Accountability

  • Identify patient panels for which providers are responsible
  • Collaborate with sub-specialty providers to increase communication and shared care planning
  • Establish processes for following up with patients who have recently been discharged from the hospital or ED
  • Ensure access for timely post-hospital follow-up visits

Medication Reconciliation

  • Complete comprehensive medication review and reconciliation of any discrepancies or contraindications
  • Provide patient with an updated list of medications to include dosing and schedule
  • Ensure patient’s ability to obtain all prescribed medications

Standardized Communication

  • Follow standard transition documentation guidelines when making referrals to other providers
  • Create process and standards for sharing information between referring provider and receiving provider with clear definitions of responsibility for follow-ups with patient/family
  • Reduce unnecessary and duplicative testing

Warm Handoffs

  • Ensure clinician-to-clinician discussion for complex patient care needs in order to communicate important details that may affect the patient’s care plan
  • Establish a protocol within your practice for receiving warm handoffs from other care providers

Patient and Family Engagement

  • Develop a process for regular patient follow-up for a fixed period after an acute event to ensure adherence to care plans
  • Educate patient/family on “red flag” symptoms and what to do; use teach back to check for understanding
  • Assess opportunities to deploy your staff for high value care coordination
  • Use established guidelines for shared decision-making with patients
    and families. You can access shared decision-making resources and patient education materials at

Community Engagement

  • Engage with local community resource providers to provide comprehensive support options for patients
  • Develop or deploy psychosocial assessments within EMR to identify potential barriers to care
  • Use existing and readily available resource libraries, such as

How Your Practice Can Address Transitions of Care

Practice Assessmentfor Transitions of Care

Complete this 5-10 minute online survey to benchmark your current performance. Your responses will be assessed by your Network quality improvement team and used to offer specific recommendations such as helping you:

  • Evaluate current practice operations and how they affect care transitions.
  • Determine a good starting point for improving transitions of care in your practice.
  • Learn the best ways for your practice to use the transitions of care toolkit.

practice link:

How Vhan Can help Your Practice

VHAN staff can help your practice offer more personalized and effective care to all of your patients. This can include helping you streamline medication lists, improve access to care, offer community resources, and support your patients’ long-term health goals.
Specifically, we offer:

Care Management Support

A team of highly trained nurses, pharmacists, and licensed social workers acts as an extension of your practice, providing you with additional clinical support such as:

  • Community resource and service coordination (i.e. transportation, meal delivery, adult day-care, caregiving, etc.)
  • Comprehensive medication reconciliation and reviews
  • Liaison with SNF, DME, Home Health providers to ensure patient needs are met
  • Disease and symptom management education

Best Practice Sharing

Personalized guidance based on best practices from your peers.

Performance Benchmarking

Tracking your improvement while also comparing your performance to the network as a whole.

Process Improvement

Support for implementing new processes and procedures to improve your performance.

Content Hub

Helpful tools and documents available for reference and download.


Post-Discharge Follow-Up

    The following timeline of key post-discharge activities will help keep your follow-up with your patients on track. In this section, you will find helpful tools to assist you.



    24-48 business hours post hospital/
    post-acute discharge

    Phone call to patient

    2-14 days post hospital/post-acute discharge

    Appointment with primary care.

    For high risk patients:
    10-14 days post hospital/post-acute discharge

    Follow up phone call

    All patients: 25-30 days post hospital/
    post-acute discharge

    Follow up phone call

    In the remainder of this section, you will find a series of tools to support your post-discharge efforts. These include scripts for patient outreach, a follow-up visit checklist medication reconciliation form and examples of patient education materials.

    Additional Resources

      Now available on the VHAN content hub.

      The content hub holds resources created for network members to access on their phone, desktop or tablet. These resources help support your organization’s efforts in addressing key clinical initiatives such as:

      • Admissions & readmissions
      • Post-acute care transitions
      • ER utilization
      • Care paths/care standardization
      • Pharmacy management
      • Targeted care coordination

      The hub includes toolkits, patient education resources that can be branded for individual practices or health systems, care paths, videos, webinars, infographics and more. Additionally:

      • Each resource can be downloaded, printed, and distributed as needed.
      • Members can use the print shop (directly linked to the hub) to order high-quality materials and brochures.
      • Members can get up-to-date information about VHAN events and new resources at a glance.

      Visit the content hub at for more tools and resources specific to transitions of care.

      Who to Contact

        Let’s work together to improve transitions of care.

        Need more information on how to access the resources outlined in this toolkit?

        If you are ready to take the next step, Vanderbilt Health Affiliated Network is here to help.

        Contact us at today and receive a personal consultation for your practice.