Provider Insider

Care Management

| Issue No. 11

Best practices in making transition of care calls.

Transitions of care (TOC) “refers to the movement of patients between health care practitioners, settings and home as their condition and care needs change.”1 Discharging from an acute setting, and for 30 days after, is increasingly recognized as a time of vulnerability for patient safety and care. The objective for the C3 transition of care program is to support the patient as they move between levels of care, reduce the likelihood of the patient returning to the hospital, and contribute to improving readmission rates by understanding reasons for 30-day readmissions.

According to Agency of Healthcare Research and Quality (AHRQ), the two most common areas of confusion among patients after a hospitalization are understanding discharge instructions and medication changes. Compliance with discharge instructions have been linked with reduced rehospitalization, improved post-hospital outcomes, and decreased health care expenditures. Medication changes or discrepancies are cited as the most frequent cause of patient misunderstanding.2

Nurse care managers review discharge instructions with patients and caregivers.

They help patients understand key points about their care such as “red flag” symptoms and who to contact for concerns and to arrange follow-up care. They also assess for social determinants of health and coordinate supportive community services, such as connection to mental health providers.

Nurse care managers reconcile medications.

Most medical records do not share data. Hospital discharge medication lists might conflict with a patient’s home list, have recommended changes in medications or doses, or not be displayed in a patient-friendly format. Care managers reconcile the hospital medication list with the active list in the primary care record, assess for discrepancies, communicate errors with primary care providers, and educate patients.

The C3 care management team supports network providers by outreaching patients following hospitalizations and ED visits. This helps reduce the risk of readmission by ensuring patients have the resources they need to self-manage at home. In Q1-Q2 2021, the C3 care management team reached out to more than 1,500 patients across the C3 network.

If your practice is not currently receiving care management support and would like to utilize this free service, please contact Jenn Countryman.


[1]   The Joint Commission, et al. “Transitions of Care: The need for a more effective approach to continuing patient care.” Digital file, June 2012.

2    Agency for Healthcare Research and Quality (AHRQ). Chartbook on Care Coordination: Transitions of Care. Retrieved from