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The Transition of Care Tool leverages existing clinical information to document an individuals mental health needs and support a referral for a transition of care or addition of services from the MCP or MHP as determined through an individualized clinical assessment of need.
Transition of Care: The right to uninterrupted health care for a specific medical condition from the first point of contact to the point of resolution or long- term maintenance with the same provider in certain cases even when the provider has terminated their contract.
Transitional Care Planning is a patient-centered, interdisciplinary process that begins with an initial assessment of the patients potential needs at the time of admission and continues throughout the patients stay.
Transitional Care Planning is a patient-centered, interdisciplinary process that begins with an initial assessment of the patients potential needs at the time of admission and continues throughout the patients stay.
Transitional care models assist chronically ill patients and seniors transitioning between healthcare settings. The Transitional Care Model (TCM) revolves around a nurse-led interdisciplinary team that improves patient outcomes while reducing hospital readmissions.

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For example, in the course of an acute exacerbation of an illness, a patient might receive care from a PCP or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility.
A transfer of care occurs when one physician turns over responsibility for the comprehensive care of a patient to another physician.
What is Transitional Care? Transitional care addresses the needs of patients in a declining state of health who are not yet ready to enter hospice care. Patients may continue to receive life-prolonging treatments in additional to palliative care that focuses on comfort measures and pain relief.

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