Transitions of Care Consensus Policy Statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Vincenza Snow, MD; Dennis Beck, MD; Tina Budnitz, MPH; Doriane C. Miller, MD; Jane Potter, MD; Robert L. Wears, MD; Kevin B. Weiss, MD, MPH; Mark V. Williams, MD


August 13, 2009

In This Article

Future Challenges

In addition to the work on the principles and standards, the TOCCC uncovered six further challenges which are described below.

Electronic Health Record

There was disagreement in the group concerning the extent to which electronic health records would resolve the existing issues involved in poor transfers of care. However, the group did concur that: established transition standards should not be contingent upon the existence of an electronic health record and some universally, nationally-defined set of core transfer information should be the short-term target of efforts to establish electronic transfers of information

Use of a Transition Record

There should be a core data set (much smaller than a complete health record or discharge summary) that goes to the patient and the receiving provider, and this data set should include items in the core record described previously.

Medical Home

There was a lot of discussion about the benefits and challenges of establishing a medical home and inculcating the concept into delivery and payment structures. The group was favorable to the concept; however, since the medical home is not yet a nationally defined standard, care transition standards should not be contingent upon the existence of a medical home. Wording of future standards should use a general term for the clinician coordinating care across sites in addition to the term medical home. Using both terms will acknowledge the movement toward the medical home without requiring adoption of medical home practices to refine and implement quality measures for care transitions.

Pay for Performance

The group strongly agreed that behaviors and clinical practices are influenced by payment structures. Therefore, they agreed that a new principle should be established to advocate for changes in reimbursement practices to reward safe, complete transfers of information and care. However, the development of standards and measures should move forward on the basis of the current reimbursement practices and without assumptions of future changes.

Underserved/Disadvantaged Populations

Care transition standards and measures should be the same for all economic groups with careful attention that lower socioeconomic groups are not forgotten or unintentionally disadvantaged, including the potential for "cherry-picking". It should be noted that underserved populations may not always have a medical home because of their disadvantaged access to the health system and providers. Moreover, clinicians who care for underserved/disadvantaged populations should not be penalized by standards that assume continuous clinical care and ongoing relationships with patients who may access the health system only sporadically.

Need for Patient-Centered Approaches

The group agreed that across all principles and standards previously established by the SUTTP coalition, greater emphasis is needed on patient-centered approaches to care including, but not limited to, the inclusion of patient and families in care and transition planning, greater access to medical records, and the need for education at the time of discharge regarding self-care and core transfer information.


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