|TC Strategy and Definition||Hospitals Adopted||Patients Exposed c|
|1. Identification of Caregiver b||42||100.0%||7939||100.0%|
|• Organization identifies patients’ family caregiver.|
|2. Interdisciplinary Approach b||41||97.6%||7927||99.9%|
• Organization has a designated team that facilitates the implementation of TC efforts.|
• Organization uses Designated Interdisciplinary Rounds/Huddles/Meetings and Electronic Health Record to communicate about patients’ discharge or TC needs.
|3. Standard Protocol b||41||97.6%||7814||98.4%|
|• Organization uses a standardized template for discharge summaries.|
|4. Transition Team||38||90.5%||7242||91.2%|
|• Organization routinely uses a specific transition team (i.e., care coordination) to coordinate TC plans across hospital and post-home sites of care to a great extent or somewhat|
|5. Transition Summary for Patients and Family Caregivers||36||85.7%||7380||93.0%|
|• Organization consistently provides patient-centered transition record (e.g., list of diagnoses, allergies, medications, physicians, contact information) to patients/caregivers to a great extent.|
|6. Language Assessment||35||83.3%||6804||85.7%|
• Organization consistently identifies, communicates and offers interpreter service to patients who need it to a great extent.|
• Organization consistently provides educational materials in the language that patients prefer, if patients are non-English speaking to a great extent or somewhat.
|7. Medication Reconciliation||35||83.3%||7316||92.2%|
• Contacts are usually or always made with outside pharmacies and/ or primary care providers for clarifying a patient’s current medication list when needed (i.e. medication reconciliation).|
• A designated person is responsible for conducting medication reconciliation at discharge.
|8. Home Visits||34||81.0%||6259||78.8%|
|• Hospital or a community-based organization conducts home visits after discharge, for all, most, or some patients receiving TC services by a care coordinator or equivalent.|
|9. Patient Goal/Preference Assessment||33||78.6%||6240||78.6%|
|• Organization identifies patient’s health goals and preferences.|
|10. Identify High-Risk Patients and Intervene||33||78.6%||6296||79.3%|
• Organization uses a protocol or tool to identify who is at high risk of readmission or have high-risk scenarios that could potentially results in poor outcomes.|
• Organization consistently uses a protocol/risk assessment tool to identify patients in need of TC services somewhat or to a great extent.
• Organization uses at least 6 of the 11 criteria below to identify patients in need of TC services
o Certain Diagnoses of Comorbidities
o Cognitive impairment
o Emotional / Psychological status (Depression, Anxiety, etc.)
o History of Mental Health/Behavioral Health Issues
o Lack of social support (consistent caregiver, transportation, etc.)
o Language barriers
o Limitations with physical functioning (e.g., frailty, deconditioning, unable to perform on ADLs)
o Limited/Poor health literacy
o Problems with medications (Polypharmacy and/or high-risk medication such as anticoagulants)
o Socioeconomic status (e.g., financial issues, homelessness, etc.)
o Substance Use (History, current use or inappropriate use of alcohol, prescriptions medications, or illicit drugs)
o Use of hospital/emergency department within last 30 days
o Use of hospital/emergency department within last 90 days/3 months
• Organization implements risk-specific interventions tailored to a patient’s individual risk of poor outcomes or other post-discharge adverse event (e.g., referral to community services or outpatient case managers for patients with psychosocial issues) to a great extent or somewhat.
|11. Follow-up Appointment||32||76.2%||6100||76.8%|
|• On the day of discharge, patients receiving TC services always or usually leave the hospital with an outpatient follow-up appointment already arranged.|
|12. Referral to Community Services||29||69.1%||5512||69.4%|
|• Organization routinely make referrals and/or arrangements for community-based services to a great extent? (e.g., transportation assistance, Meals on Wheels, etc.)|
|13. Post-Discharge Care Consultation||27||64.3%||4868||61.3%|
• Organization regularly calls all or most patients receiving TC services after discharge to follow up on post-discharge needs or to provide additional education.|
• For patients discharged to skilled nursing facilities or with home health services, organization usually or always provides direct contact information for an inpatient physician to contact in case of questions.
|14. Timely Exchange of Critical Patient Information among Providers||27||64.3%||5604||70.6%|
• There is a reliable process in place to ensure outpatient care providers (i.e., primary care physicians) are alerted to the patient’s hospital admission within 24 h of admission.|
• A patient’s discharge summary typically completed and available for viewing in the EMR or printed on paper either at discharge, within 48 h, or within 72 h.
• For all or most patients, a paper of electronic discharge summary is sent directly to the patient’s primary care providers or post-acute providers such as nursing homes/SNFs, home health agencies, etc.?
• Outpatient care and community service providers have access to all or most inpatient electronic records.
• At the time of hospital discharge, goals and preferences (e.g., Goals of Care or DNR status) for all or most patients are communicated to primary care providers or post-acute providers (e.g., SNFs, home health)
|15. Patient/Family Caregiver Transitional Care Needs Assessment||25||59.5%||5135||64.7%|
• Organization assesses patient’s TC needs using explicit criteria|
• Organization assesses family caregiver’s TC needs using explicit criteria
• As part of the discharge process, staff or a designated person routinely asks patients whether they can afford their medications for some or all patients depending on the medications
|16. Teach Back for Information and Skills||15||35.7%||2041||25.7%|
• Organization assesses patient’s learning capability and style|
• Organization formally uses the Teach Back Method 
• Organization provides opportunities for patients and families/caregivers to learn new information or skills needed for self-care at home
• Organization provides opportunities that allow patients and family/caregivers to practice new skills needed for self-care to a great extent or somewhat