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(tran-ZIH-shuh-nul kayr) Support given to patients when they move from one phase of disease or treatment to another, such as from hospital care to home care. It involves helping patients and families with medical, practical, and emotional needs as they adjust to different levels and goals of care.
This final rule focused on driving interoperability and patient access to health information by liberating patient data using CMS authority to regulate Medicare Advantage (MA), Medicaid, Childrens Health Insurance Program (CHIP), and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs).
The Centers for Medicare and Medicaid Services (CMS) provides health coverage to more than 100 million people through Medicare, Medicaid, the Childrens Health Insurance Program, and the Health Insurance Marketplace.
Transition of Care The movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another.
Care transitions occur when a patient moves from one health care provider or setting to another.
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Care transitions can be defined as the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.29 Interventions to improve transitions or transitional care are a set of actions designed to ensure the coordination
CMS defines a hospital readmission as an admission to an acute care hospital within 30 days of discharge from the same or another acute care hospital. It uses an all-cause definition, meaning that the cause of the readmission does not need to be related to the cause of the initial hospitalization.
CMS is the federal agency that provides health coverage to more than 160 million through Medicare, Medicaid, the Childrens Health Insurance Program, and the Health Insurance Marketplace. CMS works in partnership with the entire health care community to improve quality, equity and outcomes in the health care system.

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