Building the Infrastructure That Earns the Designation

Background

The organization had held URAC Health Plan accreditation for six years. Its care transitions work had grown organically — case managers coordinating discharges, a pharmacy team performing some medication reviews, and a discharge planning nurse embedded at its two highest-volume hospital partners. The work was real. The documentation infrastructure was not.

When the organization's state Medicaid contract came up for rebid, the RFP included a new requirement: evidence of a structured, independently validated transitions of care program. The organization's leadership pointed to its existing case management operation as the answer. The RFP evaluators were not satisfied — they wanted a named credential, not a description of activities.

The organization applied for the URAC Transitions of Care Designation independently, without consulting support. The review resulted in four RFIs across three of the five TOC standards. The organization withdrew the application rather than respond to RFIs it did not know how to address.

IHS was engaged eighteen months later, when the contract rebid was approaching again.

What the Gap Analysis Found

IHS conducted a Standard-by-Standard Review against all five URAC TOC standards within the first three weeks of engagement. The findings confirmed the pattern IHS has observed repeatedly: the operational work was largely present; the infrastructure to document, assign accountability for, and consistently execute that work was not.

Standard 1 — Risk Identification

The organization had a risk stratification model embedded in its care management platform. However, the criteria for flagging patients as high-risk for poor transitions were not formally documented in policy, and the stratification logic had been modified multiple times without written rationale. URAC reviewers cannot credit operational processes that are not anchored to documented, approved criteria.

Gap: Risk identification criteria not formalized in policy; modification history not documented.

Standard 2 — Comprehensive Transition Assessment

Case managers were completing transition assessments, but the assessment tool had not been reviewed or approved at a governance level in three years. The tool covered medical and functional status adequately but had minimal behavioral health and social determinants content — gaps that URAC's standard addresses explicitly. Additionally, timeliness of assessment completion varied widely and was not tracked.

Gap: Assessment tool outdated and not governance-approved; behavioral health and social determinant domains inadequate; timeliness not monitored.

Standard 3 — Medication Reconciliation

This was the most significant gap. The pharmacy team performed medication reviews for a subset of high-acuity patients, but accountability for the reconciliation — which specific clinician was responsible for signing off — was not formally assigned. Reviews were sometimes completed by pharmacy technicians without pharmacist sign-off. The reconciled medication list was communicated to patients verbally; written communication to receiving providers was inconsistent and not documented.

Gap: Accountability not formally assigned; pharmacist sign-off not consistently required; written communication to receiving providers not documented; no timeframe tracking.

Standard 4 — Dynamic Care Management Plan

Care plans existed but were structured as episode-specific documents — they addressed the acute event, not the care continuum. Plans were rarely updated after the initial transition was complete, even when patients experienced subsequent transitions. Cross-setting care plan sharing with post-acute providers was informal and not consistently documented.

Gap: Care plans episode-focused rather than continuum-spanning; update triggers not defined; cross-setting sharing not systematically documented.

Standard 5 — Transition Information Communication

Communication occurred but was not uniformly documented. Case managers sent transition summaries to receiving providers by fax; confirmation of receipt was not systematically tracked. Patient and caregiver education at transition was verbal; written materials were not consistently provided or documented as provided. No timeframe monitoring existed for any communication requirement.

Gap: Receipt confirmation not tracked; patient/caregiver written education not consistently provided or documented; no communication timeframe monitoring.

The Rebuild Plan

IHS structured the engagement in four phases, designed around the look-back period requirement. URAC would need to see evidence of operational compliance over a meaningful pre-survey window — which meant the rebuilt processes had to be operating and generating documentation well before the AccreditNet submission date.

Phase 1: Policy and Procedure Architecture (Months 1–2)

IHS developed or revised policies for all five TOC standards, working directly from the URAC standards text rather than from templates. Each policy was structured to be both URAC-compliant and operationally executable by the staff who would implement it. Policies that sounded compliant on paper but did not match how the organization actually worked were rejected in favor of documentation that reflected real operations — then modified where real operations needed to change.

The medication reconciliation policy received the most intensive revision. IHS drafted an accountability assignment framework that designated the clinical pharmacist as the responsible party for each reconciliation, with defined escalation paths for complex polypharmacy cases. The policy was reviewed by the organization's pharmacy director and medical director before governance approval.

Phase 2: Operational Infrastructure Build (Months 2–5)

Policy alone does not satisfy URAC. IHS worked with the organization's IT and operations teams to implement the tracking and documentation infrastructure that the revised policies required:

• Risk stratification criteria formally documented and version-controlled in the care management platform
• Assessment tool revised to include validated behavioral health screening and social determinants domains; governance-approved and dated
• Medication reconciliation workflow redesigned: pharmacist accountability assignment built into the care management platform workflow; written reconciliation summaries generated automatically for each reconciliation event; fax confirmation tracking implemented
• Care plan template revised to span the full care continuum; update triggers formalized (any subsequent transition, any significant clinical change, 30-day interval minimum); cross-setting sharing documented via the care management platform
• Communication tracking module implemented: automated logging of transition summary send date, fax confirmation receipt, and patient education material distribution

Phase 3: Look-Back Period Operation (Months 3–8)

The rebuilt processes were operational by Month 3. IHS monitored compliance data monthly throughout the look-back period, identifying and addressing execution gaps before they accumulated into patterns that would be visible to URAC reviewers. Monthly compliance reports were reviewed in joint calls with the organization's care management leadership.

Two execution gaps surfaced during look-back monitoring that would have generated RFIs if not caught:

• Receiving provider communication timeframes were being met for hospital-to-home transitions but not consistently for hospital-to-SNF transitions, where the receiving facility was identified after the communication window had opened. IHS identified a workflow adjustment — initiating the communication to the discharge planner rather than waiting for the receiving facility to be confirmed — that closed the gap.
• Care plan update documentation was inconsistent for patients who experienced secondary transitions within 30 days of the initial transition. IHS implemented a secondary transition flag in the care management platform that triggered an update documentation prompt.

Phase 4: Mock Survey, Submission, and Designation (Months 8–10)

IHS conducted a full mock survey in Month 8, structured to replicate URAC's document review process. The mock survey identified two residual documentation gaps — both in the transition assessment timeliness tracking reports — that were remediated before submission.

The AccreditNet submission was organized by standard, with evidence clearly labeled and cross-referenced to the relevant standard language. IHS drafted a brief reviewer narrative for each standard explaining the operational structure and directing the reviewer to the relevant evidence.

URAC issued one RFI — on Standard 3 (Medication Reconciliation), requesting additional case-level evidence of pharmacist sign-off on reconciliations completed during the look-back period. IHS prepared a targeted response with a sample of reconciliation records demonstrating pharmacist accountability, accompanied by a brief explanatory narrative. The RFI was resolved in a single response cycle. The URAC Transitions of Care Designation was awarded in Month 10 of the engagement.

Outcomes

What This Engagement Illustrates

This organization's experience reflects the most common pattern IHS observes in TOC Designation engagements: organizations that are doing genuine care coordination work, but have built that work on informal foundations that cannot survive external review. The gap between "we do this" and "we can document that we do this consistently, within defined timeframes, with assigned accountability" is where most organizations fail.

The URAC TOC Designation does not ask whether care transitions work is happening somewhere in the organization. It asks whether it is happening in a structured, documented, and consistently executed way that an outside reviewer can verify. That distinction drives the entire engagement.

Thomas G. Goddard, JD, PhD — former Chief Operating Officer and General Counsel of URAC — led this engagement personally, as he does every IHS engagement.