Composite Measures and Items | Factor Loading | |||
---|---|---|---|---|
Downstream | Ambulatory | Hospital | ||
Effort in Coordinating Patient Care | ||||
 Q6 | It is easy to get information about a recently discharged patient. | 0.76 | 0.79 | 0.66 |
 Q7 | It is easy to connect with providers and staff in the hospital to discuss a patient’s care. | 0.73 | 0.73 | 0.83 |
 Q8 | It is clear what in-patient procedures and tests have been performed and the results. | 0.86 | 0.85 | 0.80 |
 Q10 | Everyone involved in the patient’s care understands what needs to be done for the patient. | – | – | 0.84 |
Quality of Patient Information Received | ||||
 For recently discharged patients, how often is the information you receive: | ||||
 Q11 | In a format where it is easy to find important information? | 0.84 | 0.87 | 0.81 |
 Q12 | Complete? | 0.82 | 0.88 | 0.82 |
 Q13 | Available as soon as it is needed? | 0.84 | 0.87 | 0.79 |
 Q14 | Clear about who to follow up with at the hospital if you have questions or concerns about the patient? | 0.73 | 0.80 | 0.83 |
Organizational Support for Transitional Care | ||||
 Q17 | My organization is implementing activities to improve transitional care for patients. | 0.81 | 0.65 | 0.66 |
 Q18 | Senior leaders in my organization dedicate adequate resources to support effective transitional care for patients. | 0.89 | 0.95 | 0.88 |
 Q20 | My organization tries to increase physician awareness and understanding of the services we provide that can assist recently discharged patients. | 0.81 | – | – |
Access to Community Resources | ||||
 In the local area your organization serves, patients have adequate access to: | ||||
 Q21 | Primary care providers. | 0.76 | 0.65 | 0.75 |
 Q22 | Specialty providers. | 0.79 | 0.70 | 0.76 |
 Q23 | Skilled nursing and rehabilitation facilities. | 0.70 | 0.75 | 0.66 |
 Q24 | Mental health/behavioral health services. | 0.63 | 0.70 | 0.59 |
 Q25 | In-home support services (e.g., home health aides/ technicians or other services that help patients remain in their homes). | 0.69 | 0.76 | 0.59 |
 Q26 | Transportation for medical-related services. | 0.60 | 0.67 | 0.48 |
Strength of Relationships Among Community Providers | ||||
 How would you describe the relationship between you and the following providers in working together to provide transitional care to patients? | ||||
 Q27 | Primary care providers and specialists. | 0.54 | 0.63 | 0.68 |
 Q28 | Skilled nursing and rehabilitation facilities. | 0.78 | 0.90 | 0.89 |
 Q29 | Home health agencies. | 0.90 | 0.88 | 0.90 |
 Q30 | Community-based organizations. | 0.74 | 0.80 | 0.80 |