New Transitions of Care Credential Program for Case Managers

Wednesday, September 14th, 2011
This post was written by Cheryl Miller

A timely new certification in care transitions recognizes skills and expertise in patient handoffs between sites of care.

The Case Management Society of America (CMSA) and the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) are collaborating to create a sub-specialty certification for transitions of care (TOC.) According to the CMSA web site, this new credential is

“the first one to support professionals not only as a team, but also individually, who demonstrate competence and skills in providing the key elements of transitions of care.”

Successful transitions of care from one managed care environment to another are key to reducing hospital readmissions and improving overall healthcare costs and patient satisfaction. According to market research compiled in Healthcare Intelligence Network’s second annual Managing Care Transitions Across Sites survey conducted in May 2010, the hospital-to-home transition is the most critical transition in care, followed by skilled nursing facility (SNF)-to-home (49.2 percent) and ER-to-home transitions (45.9).

But until now, care transitions haven’t traditionally been part of medical education and training; according to the American Geriatrics Society:

  • Nearly 20% of Medicare patients readmitted to hospital within a month
  • Patients are frequently confused and dissatisfied by the discharge process
  • Communication between hospitalists and PCPs is equent
  • And patients are suffering: from those recently hospitalized who are often discharged without proper instructions on what medications to take or resume taking to faulty or incomplete handoffs of patients between provider shifts in teaching hospitals that may be responsible for more medical errors than overworked, sleep-deprived medical residents.

    The majority of HIN’s survey respondents said that post-transition patient contact, such as home follow-up visits and post-discharge telephone calls, were the most successful strategies to improve care transitions.

    And more than half of the respondents said that the case manager was most frequently charged with care transition management.

    Says Jan Van der Mei, continuum case management director at Sutter Health Sacramento Sierra Region:

    “One of the main focuses for care coordination is to avoid duplication of services when patients move from one site of care to the next. When someone is leaving the hospital, care coordination can help the patient get a follow-up appointment. When you are monitoring the patient, it may be helping them get to the office instead of going to the ED.

    “It is also many rounds of addressing the psychosocial issues and making sure that patients can actually make it to their appointments – that they have transportation and that when they get a new prescription, they are able to pick up the prescription and pay for it,” Van der Mei continues.

    Other elements for care coordination involve making sure when a PCP refers a patient to a specialist, that the specialist has the necessary information so they can provide the assessment that is being sought without actually duplicating tests that have already been done, recommends Van der Mei.

    Says Mary Beth Newman, MSN, RN-BC, CMAC, CCP, CCM, as quoted on the CMSA web site:

    “…we have worked hard to design the credential to help identify best practices, as well as to assist case managers in making recommendations that balance the appropriateness of health care services with cost and quality as related to transitions. It is vital that the program address the need for effectiveness, efficiency, equity, safety, and timeliness in transitions of care.”

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    2 Responses to “New Transitions of Care Credential Program for Case Managers”

    1. Jennifer Arledge says:

      I am the manager of Inpatient Case Management of a 700+ bed hospital in the eastern US. I would like more information about this certification. email address

    2. Melanie Matthews says:

      Jennifer, for more details on the care transition certification, please visit: