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Initiatives > Transitions of Care

Transitions of Care (TOC) interventions are focused on improved care coordination across the healthcare delivery system to help ensure seamless transition of patients between primary care, specialty care and hospital-based settings.


  • Emergency Department (ED)/Inpatient Notification: Utilization of an electronic system to alert primary care providers about patient visits to emergency departments (ED) or admissions into inpatient settings. This electronic system will also support the transmission of relevant clinical data from the ED visit or inpatient admission (e.g., ED triage, treatment, and discharge information) in a standard format that can be incorporated into primary care practice electronic medical record systems and chronic care management frameworks.
  • Electronic Specialty Care Referral: Relevant clinical information is electronically transmitted between the primary care practice and specialists in standard formats that can be incorporated into each practice’s electronic medical record system and utilized to guide care.


The implementation of Transitions of Care and Chronic Care Management interventions are supported by the following CCBC initiatives:

  • Primary Care Development Corporation (PCDC) Practice Coaching and Learning Collaborative: CCBC has engaged PCDC, which throughout 2012 is providing hands-on practice coaching and implementing learning collaboratives with 18 primary care practices. The PCDC practice coaches, in conjunction with members of the CCBC Clinical QI Team, are working with practices on an individual basis to implement the chronic care management interventions in a manner tailored to the specific needs, resources, and structure of individual practices. In addition, PCDC is conducting five learning sessions that focus on the following topics: QI Foundation, Care Management Frame work, Clinical Decision Support, Process Workflow Redesign, Sustainability and Spread. The PCDC practice coaching and learning sessions are also closely aligned with the implementation of the TOC interventions.
  • HIT Use Optimization Efforts:  (1) Facilitation of NCQA Patient-centered Medical Home certification and Meaningful Use Stage 1-related EMR enhancement development; and (2) Facilitation of EMR functionality and configuration developments, associated workflow mapping and redesign to optimize primary care practice use of ED/Inpatient Notification and Electronic Specialty Care Referral information.
  • QI Funding Subaward Program: The goal of this program is to increase capacity and capabilities to enable direct allocation of resources by CCBC partner primary care practices and hospitals to engage in quality improvement activities that support the CCBC goals and interventions.
  • Greater New Orleans Health Information Exchange: The Greater New Orleans Health InformationExchange (GNOHIE) is a community-shared HIT infrastructure that will facilitate care coordination and chronic disease management by enhancing information and process linkages across health systems and improving the quality of care at the population level.


The TOC initiative is being developed and piloted by three providers in New Orleans:  Daughters of Charity, NO/AIDS Task Force, and Tulane Community Health Center. Health information technology (HIT) is being used to automate and integrate work processes at primary care clinics through improved health information exchange.  Health information will be electronically and seamlessly exchanged between primary care, specialty care and emergency care providers to improve the ability of clinicians to make the best clinical decisions for patients, as well as to reduce duplication of services and improve adherence to care plans.