Hancock Regional Health’s IT leadership team sought an efficient solution to implement Transitions of Care documents, also called Continuity of Care documents (CCD) mandated by the federal government. This care summary document must be sent to the “next in line” provider, regardless of what technology solution they use to support patient care.


From an IT perspective, IHIE has extensive experience with documentation and document management through its DOCS4DOCS Service. The D4D Service provides the backbone to deliver these CCDs to these “next in line” providers. It is the delivery of the document that is the key to meeting the federal requirement, and IHIE can do this efficiently and quickly on behalf of HRH. By partnering with IHIE for this service, HRH leverages its existing connections to IHIE and the connections that IHIE has with 25,000 providers in the state to deliver the information.

From an IT perspective, IHIE has strong project management processes to help support this service. And, from a clinical perspective, IHIE is able to combine the information sent by HRH into a useable and consistent format across the entire IHIE network.

As an added value to HRH, IHIE runs a report of the CCD documents that were actually delivered to the providers. HRH is able to match that up against their report of ToC documents that they sent. This reconciliation process is important for HRH to ensure they are delivering the appropriate percentage to meet the federal requirements, but is also a best practice for patient care.


Donata Barnes
Director, Health Care Collaboration
CICOA Aging & In-Home Solutions
Clinical setting: Other / CareWeb


  • Supports better communication between clients and CICOA care managers
  • Saves staff time and frustration searching for clinical information
  • Provides better and faster support to assist clients to line up additional assistance for clients
  • Project serves as example of impactful way to manage healthcare expenses; could serve as model to commercial payers


“Our care managers often don’t get all their previous care information from their clients. They can look at CareWeb so they aren’t constantly looking into the same problem. It saves us time and resources.”
“The layout of CareWeb is simple and easy to navigate.”