Care Management/ Care Coordination/ Transitions of Care

Transitions of Care

Track patients through hospital admission, discharge planning, and post-discharge follow-up to reduce readmissions

Admitted3
Maria Gonzalez
Admitted: Mar 30, 2025
CHF Exacerbation
Riverside Medical Center
CM: Rosa Diaz
High Risk
James Thompson
Admitted: Mar 31, 2025
Hip Fracture / Surgery
County General Hospital
CM: David Park
Moderate Risk
Sunita Patel
Admitted: Apr 1, 2025
Pneumonia
St. Mary's Hospital
CM: Rosa Diaz
Low Risk
Hospitalized3
Robert Williams
Admitted: Mar 27, 2025
COPD Exacerbation
Riverside Medical Center
CM: Maria Santos
High Risk
Janet Kim
Admitted: Mar 26, 2025
Diabetic Ketoacidosis
County General Hospital
CM: Rosa Diaz
Moderate Risk
Emeka Okonkwo
Admitted: Mar 28, 2025
Cellulitis / IV Antibiotics
St. Mary's Hospital
CM: David Park
Low Risk
Discharge Planning2
Carlos Rodriguez
Admitted: Mar 23, 2025
ACS / Post-Cath
Riverside Medical Center
CM: Rosa Diaz
High Risk
Lisa Chen
Admitted: Mar 25, 2025
Asthma Exacerbation
St. Mary's Hospital
CM: Maria Santos
Moderate Risk
Post-DC Follow-Up2
David Nguyen
Discharged: Mar 28, 2025
CHF — DC to Home
Home Health ordered
CM: Rosa Diaz
30d Risk: 38%
Helen Foster
Discharged: Mar 24, 2025
Sepsis — DC to SNF
Sunrise Skilled Nursing
CM: David Park
30d Risk: 52%
Closed2
Mark Johnson
Closed: Mar 22, 2025
Total Knee Replacement
30-day follow-up complete
CM: Maria Santos
No Readmission
Anna Brown
Closed: Mar 18, 2025
Hypertensive Crisis
30-day follow-up complete
CM: Rosa Diaz
No Readmission
Discharge Planning Checklist — Carlos Rodriguez
ACS / Post-Cath  ·  Admitted Mar 23  ·  Riverside Medical Center  ·  Est. DC: Apr 3
Readmission Risk Scores — Carlos Rodriguez
7-Day Readmission Risk
24%
High Risk
ACS patients with EF <35%: 3× baseline risk
30-Day Readmission Risk
42%
Moderate-High Risk
LACE score: 12/19 · Multiple comorbidities
Recommended Actions
  • Schedule cardiac rehab enrollment within 7 days
  • Home health nursing 3×/week for 4 weeks
  • Telehealth visit with care manager 48h post-discharge
  • Daily weight monitoring with alert threshold >3 lb/day
Page Guide — Transitions of Care
Kanban Board
The Kanban board tracks each patient through the care transition workflow. Click any card to load the discharge checklist and risk scores below.
  • Cards are color-coded by risk level on the left border
  • Drag cards between columns to update patient status (coming soon)
  • High risk badges trigger care manager alerts
Discharge Checklist
The discharge planning checklist ensures all safe-discharge criteria are met before the patient leaves the facility. Incomplete checklists block the status change to "Post-Discharge" and generate an alert to the supervising care manager.
Readmission Risk
Risk scores are calculated using the LACE Index (Length of stay, Acuity, Comorbidities, ER visits) combined with proprietary ML model inputs. 7-day risk >20% triggers a mandatory post-discharge phone call within 48 hours.
CMS Quality Measures
The Transitions of Care module directly supports CMS quality measures: Transitions of Care (TOC), Patient Safety measures, and HEDIS FUH/FUM. 30-day all-cause readmission rate is a key Star Rating metric.