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Table 2 The ten domains of the ITC and their association with readmission reduction when part of an intervention

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)
  1. *False discovery rate-adjusted p-values are reported.