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Document a transition of care

Record a post-discharge handoff for a member: a transfer summary, a scheduled follow-up call, and (optionally) a notification to the member's primary care provider.

Before you start​

  • You need a role that can author transition notes (Nurse Care Manager or Care Coordinator).
  • In the left menu, go to Members → Transitions of Care, or start from a member's workspace via Role Actions → Transition of Care.

Steps​

  1. On the Transitions of Care page, click New Transition.
  2. Find and select the member in the search that opens. The Transition of Care form opens.
  3. Fill in the transition details:
    • Transition type — for example hospital-to-home, hospital-to-SNF, SNF-to-home, ER-to-home, home-to-rehab.
    • Discharge date — defaults to today.
    • Active diagnoses — the conditions being managed through this transition.
    • Medication changes — what's new, continued, and stopped.
    • Follow-up window (days) — defaults to 7; this sets the due date of the follow-up call.
    • PCP name (optional) — enter it to send a handoff notification to the primary care provider.
    • Warning signs to call in — for example "weight gain over 2 lb/day, shortness of breath, fever over 100.4 F".
  4. Click Save Transition. You return to the member's Face-Sheet.

When saved, the system files the transfer summary on the member's record and creates an urgent post-discharge follow-up call task due at the end of the follow-up window.

Tips / Troubleshooting​

  • The follow-up task appears on the member's Tasks & To-Do tab and in your team's task board (Collaborate → Tasks).
  • Keep the follow-up window short (7 days or less) for high-readmission-risk members.