Transitions of Care

The purpose of the LTPAC Transitions of Care (TOC) Implementation Guide is to provide a standards-based solution to support care transitions and coordination for LTPAC patients across all settings of care.


The five traditional Post-Acute Care (PAC) settings, Hospice, Home Health, Skilled Nursing, Long Term Care Hospitals, and Inpatient Rehab facilities employ many types of clinicians, practitioners, therapists, and allied professionals who each require different information to provide the best and most efficient services to their patients. This information may include standardized assessments, patient preferences, observations, and other important data. Many of these items are valuable during a transition of care from one setting to another, including settings outside of Post Acute Care such as Acute Inpatient, Emergency Department, and Home and Community Based Organizations (HCBOs). This critical information is often not exchanged, resulting in gaps in care information during initial assessments and reassessments in new or parallel settings, and the data is never available as a specific role-based data set. This leads directly to potentially unsafe transition and coordination of care for these most vulnerable patients as well as information overload, additional documentation, errors in the patient record, incorrectly reconciled data, and a burden on families and patients to carry physical records with them during transitions.

This project uses a consensus driven process among a wide variety of practicing clinicians such as physicians, nurses, Physical / Occupational / Respiratory Therapists, Speech Language Pathologists, Paramedics, and other allied providers like HCBO Professionals, Quality Measurement Experts, Administrators, and Payers to identify where essential information overlaps and build a meaningful method for exchanging it. Particular emphasis will be placed on off-the-shelf concepts and vocabulary, e.g., the CMS Data Element Library.


  • Produce and implementation guide(s) supporting transition workflows paired with key clinical data for specific post-acute care disciplines to care for a patient entering a post-acute setting.
  • Exclusively use existing resources and profiles.


The 360x project tackled post-acute transitions, but found gaps in the data need for providers. In parallel, market actors in the post-acute care tech space grappled with the same issue trying to create solutions but being limited by both the data itself, as well as a prescribed method to access it.