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Improving on Transitions of Care: How to Implement and Evaluate a Plan


This guide helps health care institutions develop and implement processes for sending and receiving patients from one care setting to another. The information and plans provided allow institutions to measure their performance in transitions of care and identify areas for improvement.

Topics covered are:

  • Introduction
  • Background
  • Evaluating and improving transitions of care in your institution
  • Nursing home to emergency department (ED)/hospital transfer
  • Appendices
    • Appendix A: Emergency medical services (EMS)/ambulance transfer of patient from a nursing home to hospital
    • Appendix B: Hospital receipt of patient from nursing home
    • Appendix C: ED/hospital to nursing home transfer
    • Appendix D: EMS transport of patient to nursing facility
    • Appendix E: Nursing home receipt of patient from the hospital
    • Appendix F: Evaluation: a basic primer
    • Appendix G: Literature review - transitions from the nursing home to the hospital
    • Appendix H: Institute for Healthcare Improvement tips for effective measures
    • Appendix I: National Transitions of Care Coalition (NTOCC) tools
    • Appendix J: NTOCC proposed framework for measuring transitions of care
    • Appendix K: Annotated bibliography and references
Links to the Tool:
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Insight Therapeutics, LLC; National Transitions of Care Coalition

Funding Sources

Sanofi-Aventis; National Transitions of Care Coalition; Case Management Society of America

QualityTool Topic


Related Resources

National Transitions of Care Coalition. Improving on Transitions of Care: Executive Summary. Available at:


  • Release Date: 04/2008
  • Original Summary: 06/2009
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Last updated: February 03, 2010.