Tools to Support Safe Care Transition Communications

As part of discharge planning, hospitals are expected to provide post-acute providers and caregivers information, including current course of illness and treatment, post-discharge goals of care, and treatment preferences, to enable safe transitions between levels of care.  The Centers for Medicare & Medicaid Services (CMS) reinforce this expectation as part of their conditions of participation and in the certification and survey process. 

The 86 IPRO QIN-QIO Partnership for Community Health (PCH) coalitions are exploring ways to enhance communication and information transfer during transitions of care. Our team of experts work with providers to assess current practices, identify evidence-based tools, and implement structured communication processes that enable provision of critical information (e.g., medications, goals of care, and co-occurring mental health and/or substance use disorders) and reduce the risk of adverse events and unplanned hospital utilization.

As one example, our medication safety team is helping providers implement the Pain Management Discharge Communication Elements, published in 2021 and developed through a subject matter expert Delphi-consensus process.  The resource outlines essential communication elements, including behavioral health, opioid use disorder, and substance use disorder diagnoses; complete and accurate medication list; and prescribing-related details for opioids.  Teams from the electronic health record company, EPIC, and IPRO collaborated to configure the communication elements in a brief, concise Pain Management Discharge Report (EPIC Foundation 2023 upgrade).

View other communication tools ( e.g., Anticoagulation Discharge Communication and Diabetes Management Discharge Communication) available in the IPRO QIN-QIO Resource Library

Contact us for help supporting safer care transitions in your community.