Viewing 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.

Follow these steps to view a transition plan.

  • Select a subset and then click Book View button.
  • Select either risk factors for readmission or an item under Expected Discharge Level of Care.
  • If necessary, expand the decision tree as follows:
  • Click a plus sign Plus sign icon to expand a section of the decision tree and click a minus sign Minus sign icon to collapse it.
  • Click Expand All to expand all criteria in the decision tree and click Collapse All to collapse it.
  • View any notes associated with the criteria by clicking the appropriate note icon:
  • Informational Note Note icon —Provide reminders of best medical practice, new clinical knowledge, procedural information, explanations of criteria rationale, and current literature references.
  • Transition Plan Note Transition Plan note—Indicate that the patient might be at a higher risk for readmission and could benefit from comprehensive discharge planning.
  • For a PDF version of the transition plan that you can print or save:
  • Click Print and then select one of the following:
  • Current Selection—Creates a printable version of the transition plan criteria you are currently viewing.
  • Full Subset—Creates a printable version of the entire transition plan subset.
  • Depending on the options available, click Open or click Download PDF.
  • Use the controls in the PDF to save and/or print the PDF.
  • When you finish viewing criteria, do any of the following:
  • Click Previous button to return to the Subset Overview screen.
  • Click Menu to exit the workflow and then, optionally, select an option from the navigation pane.