The report, “There and Home Again, Safely: Responsibilities of Ambulatory Practices in High Quality Care Transitions,” outlines five responsibilities and five principles of ambulatory practices in care transitions. This “5 x 5 model” was developed by the AMA Expert Panel on Care Transitions, which was convened by the AMA Center for Patient Safety. The panel also made a set of recommendations for each of the five responsibilities.
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Here are the five responsibilities:
1. Assessment
2. Goal-setting
3. Supporting self-management
4. Medication management
5. Care coordination
Here are the five principles:
1. Person-centered
2. Collaborative
3. Structured
4. Iterative
5. Flexible
More Articles on Care Transitions:
CMS Adds Sites to Community-Based Care Transitions Program
Robert Wood Johnson Foundation Names 5 Winners of Transitional Care Project
A Community-Based Approach to Improving Care Transitions: 4 Strategies
