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Table 6 Five Transitional Care Strategy Groups in Prospective Analysis and Requisite Strategies

From: Improving evidence-based grouping of transitional care strategies in hospital implementation using statistical tools and expert review

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)
  1. Note: N refers to number of patients exposed to each group; Patients may be exposed to more than one group
  2. TC strategies throughout the tables are ordered alphabetically by care setting (e.g., first hospital-based, then bridging, then home-based
  3. a Due to their near universal application, Identification of Caregiver, Interdisciplinary Approach, and Standard Protocols are presumed to be a part of each TC group.b Patients were exposed to other TC strategies, but not in the groups defined above