This chapter provides information on conducting a root cause analysis, assessing your organization; program policies, and procedures, and day-to-day operations; service management; assessing existing contracting and procurement processes; consumer data and health information technology; program costs and billing; staffing; training; continuous quality improvement, measurement; formal partnerships; branding; and governance boards. The COVID-19 pandemic caused certain realities when it comes to transitions. Take time to reflect on the questions below in light of the pandemic and care transitions in your community.

• What are the frequency and extent of transitions across settings during the COVID-19 pandemic?
• Where is there a breakdown?
• What is the local impact on consumers and caregivers?
• What services are currently used to support transitions between settings?
• What are the incentives for improving or continuing with the status quo?

Additional Resources

• Care Transitions September 8th Peer Hour
• Hospital Discharge Planning Worksheet

*If you would like a 508-compliant version of this document, please contact TA-Community@lewin.com.