Table 3 Transitional Care (TC) Strategy Prevalence and Definitions^a

1. Identification of Caregiver ^b

42

7939

• Organization identifies patients’ family caregiver.

2. Interdisciplinary Approach ^b

41

7927

• 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

7814

• Organization uses a standardized template for discharge summaries.

4. Transition Team

38

7242

• 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

7380

• 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

6804

• 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

7316

• 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

6259

• 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

6240

• Organization identifies patient’s health goals and preferences.

10. Identify High-Risk Patients and Intervene

33

6296

• 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

6100

• 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

5512

• 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

4868

• 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

5604

• 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

5135

• 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

2041