It runs on days, not months
Every other branch tolerates a monthly list. This one does not. An event that reaches the practice on day five has already lost the contact window, and an event that reaches it by claims has lost the whole thing.
Guide · Transitions
Transitions of care: turning a discharge into a follow-up before the window closes.
A working guide for practice administrators, care coordinators, and analysts: what a transition is and why it runs on a different clock, where the events come from, the windows that count, who owns each step, how the work is measured honestly, where it breaks, and what the platform does and does not do for it today.
By Jonan Portal Alvarez, Chief Executive Officer, Alara Healthcare (management services) · Updated September 10, 2026 · About 8 minutes
The definition
What a transition is, and why it is a branch of its own
A transition of care is the stretch between one setting and the next: a hospital discharge to home, an emergency visit that ends without an admission, a move from a skilled nursing facility back to the practice's care. It is the most dangerous week in a member's year and the most expensive one in a contract's. Readmissions inside thirty days are what plans measure, what Star Ratings score, and what a risk contract pays for twice.
It is its own branch of population health because it runs on a different clock. Risk adjustment and quality run on the calendar year. A transition runs on days: an event today, a contact within two business days, a visit within a week or two, a window that closes at thirty. A monthly cadence cannot see it. Only a daily one can.
The event comes from outside
The practice does not generate a discharge. A hospital, an exchange, a plan, or the member tells it, and each of those sources arrives at a different speed with a different share of the events. The first job of the branch is receiving.
Most of it is clinical
The follow-up visit, the medication review, and every care decision belong to the practice's clinicians. The administrative work is everything around them: receiving the event, finding the member, booking the visit, and measuring whether it happened in time.
The sources
Where the events come from
| Source | What it tells you | How fast | What to watch |
|---|---|---|---|
| Hospital event notifications | Admission, discharge, and transfer messages from the hospital or a health information exchange, with the member, the facility, and the event time. | Same day, often within hours. | Hospitals are required to send these to a patient's primary care practitioner when they can identify one. If the practice is not registered with the exchange, or the hospital does not know the member is yours, the message never comes. |
| The plan's census and authorization data | Members the plan knows are inpatient, from authorizations and concurrent review. | Daily to weekly. | Coverage depends on the plan's process. Not every admission is authorized in advance, and emergency visits usually are not on it at all. |
| Claims | The admission or the emergency visit, with diagnoses, dates, and the facility. | Weeks to months. | Too late to act on. Useful for the denominator, the readmission rate, and finding the events the notifications missed. |
| The member or the family | A call, a portal message, a walk-in. | Whenever they think of it. | The most common source in a practice with no feed, and the least reliable one. |
The clock
The windows that count
These are the windows of the Medicare transitional care management service. Most practices use them as the template for every transition, whether or not that service applies.
Day zero: the event
The discharge happens. The clock starts whether or not the practice knows, which is why the source table above decides everything that follows.
Within two business days: the contact
An interactive contact with the member or the caregiver by the practice's clinical staff, by phone, secure message, or in person. An attempt is recorded as an attempt. What counts for the service is the practice's rule to apply, and a voicemail is not a contact for the purposes of the work.
Within seven or fourteen days: the visit
A face-to-face visit, within seven days for the higher-complexity transitions and fourteen for the rest. The clinician decides the clinical content, including the medication review. The scheduler decides whether it happens at all.
Through day thirty: the readmission window
The stretch the plan measures. A member readmitted inside it counts against the practice's rate whether or not the follow-up happened, which is why the visit is only the middle of the branch, not the end.
After day thirty: the measurement
The event closes. Contact and visit timing, the readmission outcome, and the owner are recorded, and the month's events roll into the figures the administrator reads.
The people
Who owns each step
The practice's care coordinator or nurse
Owns the event from receipt to closure: the contact inside two business days, the questions the clinician wants asked, the record of what was said, and the handoff to scheduling. Clinical staff, employed by the practice, making clinical judgments.
The scheduler
Owns the visit. A follow-up slot inside the window has to exist before it can be booked, which means the schedule holds capacity for discharges it does not know about yet.
The clinician
Owns the visit's content, the medication reconciliation, the decisions, and whether the member needs more than a visit. Everything else on this list prepares that half hour.
The analyst
Owns the denominator and the figures: every admission and emergency visit from every source, matched to the member, with the contact date, the visit date, the readmission outcome, and the owner. Reports the share received on time against the share found later by claims.
The data steward
Owns the feed: the registration with the exchange, the provider mapping the hospital uses to route the message, and the identity match between the notification and the member. When an event reaches nobody, this is where the fault usually is.
The measures
How the work is measured without lying
Events received in time
The share of admissions and emergency visits the practice learned about before day two, by source. The first figure to fix, because every other one is measured only on the events you knew about.
Contact within two business days
Interactive contacts, not attempts, as a share of discharges. Read beside the attempts figure: a high attempt count and a low contact count is a phone number problem, not a staffing one.
Visit within the window
Visits kept inside seven or fourteen days, as a share of discharges. A visit booked for day twenty is a miss that looks like a success on the schedule.
Readmissions within thirty days
From claims, months later, with the denominator from the same claims. It is the plan's measure, and the only one on this list that says whether the branch worked rather than whether it ran.
An owner and a status on every event
The share of events with a named owner and a current status. An event nobody owns is a report, and in this branch a report is a readmission waiting to happen.
The honest part
Where it breaks
It works when
- The practice is registered to receive hospital notifications, and the hospital has the right clinician on file for the member.
- Every event becomes an item with an owner and a due date the day it arrives, including the ones that arrive on Friday afternoon.
- The schedule holds follow-up capacity before the discharges that will fill it are known.
- The contact is a conversation, recorded, with the clinician's questions answered.
- Claims are used to find the events the notifications missed, and the miss rate is reported, not hidden.
It breaks when
- Notifications land in an inbox nobody works, or in a fax tray.
- The hospital routes the message to a clinician who left, or to nobody, because the mapping was never set.
- The event is matched to the wrong member, or to none, because the notification's identifiers do not match the practice's.
- Weekend discharges wait until Monday and lose the contact window before anyone sees them.
- The discharge summary arrives after the visit, and the visit happens without it.
- The readmission rate is quoted without its denominator, so nobody can tell whether it moved or the events did.
The module
What Care Bridge is meant to do, and what exists today
Care Bridge is the platform's transitions module, and it is in development. It appears in the platform's navigation, but no screens sit behind it yet, and its scope and timing will be published when it ships. This guide is about the work, which does not wait for software, and the boundary below is stated so that nobody reads a plan as a feature.
Care Bridge is meant to
- Connect hospital events to the Work List, so a discharge becomes an opportunity with an owner and a due date set by the window, the day it arrives.
- Carry the contact and the visit as statuses with dates, and close the event at day thirty with its outcome.
- Report events received against events found by claims, contact and visit timing, and the readmission rate with its denominator.
What exists today
- No shipped screens. The module's scope and timing are published when it ships, not before.
- No claim of live feeds. The platform does not claim FHIR, HL7, or admission, discharge, and transfer connectivity today, and this guide does not either.
- The work runs in the practice's own process, on the windows, owners, and measures above. When the module ships, the process moves into it. It does not start there.
Where Care Bridge sits among the other modules, and its current status: Care Bridge on the platform page
Questions people ask
Questions about transitions of care
What counts as a transition?
Any move between settings that puts the member at risk in the days that follow: a hospital discharge, an emergency visit that ends without admission, a discharge from a skilled nursing or rehabilitation facility, and an observation stay. Plans measure the readmissions that follow an inpatient stay; a practice that wants fewer of them treats every one of these as an event with an owner.
We do not receive hospital notifications. Where do we start?
With registration. Hospitals are required to send electronic event notifications to a patient's primary care practitioner when they can identify one, usually through a health information exchange. Find out which exchange your hospitals use, register the practice and its clinicians, and check that the hospitals have the right clinician on file for your members. Until then, ask the plan for its census data and use claims to measure how much you are missing.
Is the two-business-day contact a phone call?
It is an interactive contact by the practice's clinical staff, which can be a call, a secure message the member answers, or an in-person conversation. An attempt is recorded as an attempt. Whether an unsuccessful attempt counts for a billable service is the practice's rule to apply under its own billing guidance; for the purposes of the work, a voicemail is not a contact.
Who decides what happens in the follow-up visit?
The clinician. The visit's content, the medication reconciliation, the orders, and whether the member needs more than a visit are clinical decisions and belong to the practice's clinicians alone. The administrative work is making sure the visit exists inside the window and that the discharge information reached the clinician before it.
How do we measure readmissions without the hospital's data?
From claims, months later. Claims give both the admissions and the readmissions, so the rate has a denominator, which the notification feed alone never does. Report the rate with its denominator and its period every time, and report separately how many of those admissions the practice knew about before the member came home.
When will Care Bridge ship?
It is in development. It appears in the platform's navigation, no screens sit behind it yet, and its scope and timing will be published when it ships. Nothing in this guide depends on it: the windows, the owners, and the measures are the work, and the work runs in the practice's own process until the module carries it.
Tell us how you learn about a discharge today.
Bring the process you have, even if it is a phone tree, and we will map it to the windows, the owners, and the measures.