From: Identifying keys to success in reducing readmissions using the ideal transitions in care framework
Domain | Description | p-value* | OR (95% CI) |
---|---|---|---|
Complete Communication of Information (CCI) | Focuses on the content of the information delivered to the receiving clinician | 0.80 | 2.2 (0.3, 13.9) |
Availability, Timeliness, Clarity, and Organization of Information (AT) | Highlights if/when this information is received by the receiving clinician, and how it is optimally presented to maximize utility | 0.80 | 1.4 (0.3, 6.2) |
Medication Safety (MS) | Medication reconciliation across the continuum of care | 0.99 | 1.0 (0.4, 2.7) |
Educating Patients to Promote Self-Management (EP) | Education to patients and caregivers, using principles of health literacy, teach-back, and encouraging self-advocacy | 0.09 | 3.3 (1.1, 10.0) |
Monitoring and Managing Symptoms after Discharge (MM) | Multi-modality interventions (telehealth, calls, visits in clinic and/or home), and a responsible clinician to respond to concerns | 0.03 | 8.5 (1.8, 41.1) |
Enlisting Help of Social and Community Supports (EH) | Adequate assessment of home environment and support and implementing help if needed | 0.07 | 4.0 (1.3, 12.6) |
Advanced Care Planning (AC) | Establish health care proxy and goals of care | N/A | N/A |
Coordinating Care Among Team Members (CCA) | Share medical records, communicate with all team members, optimize continuity of providers, formalize handoffs | 0.80 | 1.6 (0.6, 4.2) |
Discharge Planning (DP) | Emphasizes identifying patient needs prior to discharge, implementing interventions prior to discharge | 0.80 | 1.3 (0.5, 3.5) |
Follow-Up with Outpatient Providers (FO) | Follow-up with the right provider(s), appropriate time frame, preparation for visit | 0.80 | 1.2 (0.5, 3.4) |