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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