TC Strategy Groups and Patients Exposed | Required TC Strategies a | Methodological Steps Informing Group Membership |
---|---|---|
Patient Communication and Care Management (n = 2158, 27.2%) | • Patient Goal/Preference Assessment • Plain Language Communication at Hospital • Transition Summary for Patients and Caregivers • Helpful Health Care Contact OR Symptom Management • Plain Language Communication at Home • Post-Discharge Care Consultation | • Original retrospective group (Care Plan) • Factor analysis • Latent class analysis • Expert opinion |
Hospital-Based Trust, Plain Language, and Coordination (n = 2090, 26.3%) | • Identify High-Risk Patients and Intervene • Plain Language Communication at Hospital • Promote Trust in the Hospital (care and concern expressed to patients, rapport building in the hospital) • Medication Reconciliation • Transition Summary for Patients and Caregivers • Post-Discharge Care Consultation | • Original retrospective group (Medication Reconciliation; Care Plan) • Factor analysis • Latent class analysis • Finite mixture model • Expert opinion |
Home-Based Trust, Plain Language, and Coordination (n = 1979, 24.9%) | • Transition Team • Follow-up Appointment • Referral to Community Services • Home Visits • Promote Trust at Home (care and concern expressed to patients, rapport building post-discharge) • Plain Language Communication at Home | • Original retrospective group (Identify High Risk) • Latent class analysis • Finite mixture model • Expert opinion |
Patient/Family Caregiver Assessment and Information Exchange among Providers (n = 3093, 39%) | • Identify High-Risk Patients and Intervene • Patient/Family Caregiver Transitional Care Needs Assessment • Patient Goal/Preference Assessment • Timely Exchange of Critical Patient Information among Providers | • Original retrospective group (Cross-Setting Information Exchange) • Factor analysis • Latent class analysis • Expert opinion |
Assessment and Teach Back (n = 508, 6.4%) | • Language Assessment • Teach Back for Information and Skills • Post-Discharge Care Consultation | • Factor analysis • Latent class analysis • Finite mixture model • Expert opinion |
No TC Groupb (n = 2042, 25.7%) | • Not in any other group | • Original retrospective group (No TC Group) |