Transitions of Care

Transitions of Care helps care teams follow up when a patient goes to the emergency department or hospital. Zus hears about the admission as it happens, groups related encounters into one hospitalization and gathers the discharge paperwork afterward, so care managers can reach the patient with the full picture instead of a string of separate alerts.

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Learn more in the clinical guide

For how care managers use the Transitions page day to day, see Transitions of Care in the clinical guide.

What care teams see

The Transitions page in the Zus web app lists each hospitalization as one row: admit and discharge dates, status (Active or Discharged), the patient's last location, up to three diagnoses, and an icon when documents have arrived. An ED visit that turns into an inpatient stay shows as one event, not two.

Quick filters pick out Unplanned admissions (emergency, direct or holding), Behavioral health hospitalizations and Planned admissions. Other filters narrow by status, encounter type, admitting or discharge location, home state and care team provider.

Clicking a row opens the details panel: admitting and discharge diagnoses, discharge disposition, each encounter in the stay and its source documents, and a link to the patient's full record.

How it works

1. Enroll your patients. Zus receives admission, transfer and discharge (ADT) notifications for patients enrolled in a subscription that includes ADT data. Notifications come from PointClickCare (formerly Collective Medical), Bamboo Health and state and regional HIEs. See ADT Networks.
2. The patient is admitted. An ADT notification arrives and Zus adds the encounter to the patient's record. It also refreshes the record and keeps checking during the stay. Encounter notes can be available as soon as 2 hours after admission.
3. Zus groups the stay. Inpatient, emergency, observation and pre-admit encounters within 36 hours of each other become one hospitalization, stored as an EpisodeOfCare. Zus flags unplanned admissions, behavioral health and the first unplanned readmission within 30 days, using the CMS Hospital-Wide Readmission methodology. See Transition of Care Lens and Encounter Lens.
4. Your team is alerted. Care managers work the list on the Transitions page. To start a workflow in your own system instead, set up a Zushook filtered to ADT data, then fetch the hospitalization through the TOC Lens API by patient UPID.
5. The patient is discharged. The status changes to Discharged and the discharge disposition appears when it's sent. Zus checks for a discharge summary 8, 24, 48 and 72 hours after discharge, then again within a week. Documents appear in the details panel as they arrive.
6. Follow up. The care team contacts the patient with the diagnoses, discharge setting and discharge summary in hand, and opens the full record for medications and history.

What you need in place

• Patients enrolled in a subscription that includes ADT notifications
• ADT coverage where your patients are hospitalized. National networks cover many hospitals; ADT Networks lists the state and regional HIEs Zus has connected to.
• Care team users in the Zus web app, or a Zushook endpoint if you're routing alerts to your own system

In the clinical guide

• Transitions of Care: the Transitions page, filters and details panel
• Digging into TOC Logic: how encounters are grouped into hospitalizations, in clinical terms

Related pages

• Transition of Care Lens: the EpisodeOfCare data model
• Identifying high risk patients: a sample query for patients with a recent ED or inpatient visit
• Evaluating population health: ED visits and inpatient admissions per 1,000 patients
• Population Health Management