Adding a Transition Plan

A transition plan is a comprehensive discharge planning guideline that enables you to interactively manage and report on the discharge plan throughout the episode of care. It provides a framework for identifying discharge needs and outlines the interventions necessary to ensure continuity of quality patient care. Evidence has demonstrated that attention to transitioning care from one setting to another can significantly improve outcomes, impact quality of care, and reduce readmissions.

Transition Plans are available for the following products:

• Level of Care Acute Adult Criteria

• Level of Care Acute Pediatric Criteria

• Level of Care Long-Term Acute Care Criteria

• Level of Care Inpatient Rehabilitation Criteria

• Level of Care Subacute & Skilled Nursing Criteria

• Behavioral Health Adult and Geriatric Psychiatry Criteria

• Behavioral Health Child and Adolescent Psychiatry Criteria

• Behavioral Health Substance Use Disorders Criteria

A criteria point with a Transition Plan icon often indicates that the patient might be at a higher risk for readmission and could benefit from comprehensive discharge planning.

If, while conducting a review, you select one or more of these criteria points, a message displays recommending that you complete a transition plan for the patient.

Transition plans are patient-specific and are associated with an episode of care. There can be only one transition plan in progress for a patient at any given time.