Transitions of Care
This guide explains how Zus processes and organizes patient encounter data to support your clinical workflows, regardless of which system or interface you use to access this information.
Understanding Transitions of Care (ToC)
What is a Transition of Care?
A Transition of Care represents a complete episode of hospital care - from the moment a patient enters your health system until they are discharged. This might include:
- Single-location stays: Direct admission to inpatient care
- Multi-location episodes: Emergency department visit followed by inpatient admission
- Complex care paths: Transitions between observation, emergency, and inpatient settings
Clinical Value
ToC data gives you a complete picture of each hospital episode, helping you:
- Track patient outcomes across your entire care episode
- Identify readmissions and care transitions
- Monitor length of stay patterns
- Analyze discharge planning effectiveness
- Support quality improvement initiatives
How Episodes Are Defined
Zus automatically groups related encounters into episodes using:
- Shared visit identifiers when available
- Temporal proximity (encounters within 36 hours are typically grouped together)
- Clinical logic that recognizes care continuity patterns
Example Scenarios:
- Patient arrives in ED at 2:00 PM, admitted to inpatient at 8:00 PM → Single Episode
- Patient discharged Tuesday, returns to ED Friday → Two separate episodes
- Patient moves from ED to observation to inpatient over 2 days → Single Episode
Key Clinical Information in ToC Data
Episode Timeline
- Start: When the patient first entered your health system for this episode
- End: When the patient was discharged from their final encounter
- Duration: Complete length of stay across all locations
Diagnoses
- Comprehensive diagnosis list from all encounters in the episode
- Primary vs secondary diagnoses when available
- Discharge diagnoses that represent the final clinical picture
Care Locations
- Admitting location: Where the episode began
- Emergency location: ED involvement in the episode
- Discharge location: Final location before discharge
- Location transitions: Movement between departments/units
Admission Context
- Planned vs unplanned admissions
- Emergency admissions: Came through ED
- Direct admissions: Bypassed ED
- Readmission indicators: Episodes occurring within 30 days of previous discharge
Behavioral Health Flags
- Automatic detection of episodes involving mental health, behavioral, or substance use conditions
- CCSR coding integration for standardized identification
Understanding Individual Encounters
What is an Encounter Lens?
An Encounter Lens represents a single, deduplicated healthcare interaction - like one visit to the clinic, one ED visit, or one inpatient stay. It's the building block that ToC episodes are made from.
Encounter Classifications
Ambulatory (AMB): Outpatient visits, clinic appointments
Inpatient (IMP): Hospital admissions requiring overnight stay
Emergency (EMER): Emergency department visits
Observation (OBSENC): Short-stay observation care
Pre-admit (PRENC): Pre-admission processing
Readmission Detection
The system automatically identifies readmissions when:
- Current encounter is inpatient (IMP)
- Patient had another inpatient stay within 30 days
- Encounters are not within 36 hours (which would make them the same episode)
This documentation focuses on clinical applications. For technical implementation details, API specifications, or data model information, refer to theLens documentation.
Updated 3 days ago