Can the Care Transitions Measure Predict Rehospitalization Risk or Home Health Nursing Use of Home Healthcare Patients?

Abstract

The Care Transitions Measure (CTM) was designed to assess the quality of patient transitions from the hospital. Many hospitals are using the measure to inform their efforts to improve transitional care. We sought to determine if the measure would have utility for home healthcare providers by predicting newly admitted patients at heightened risk for emergency department use, rehospitalization, or increased home health nursing visits. The CTM was administered to 495 home healthcare patients shortly after hospital discharge and home healthcare admission. Follow-up interviews were completed 30 and 60 days post hospital discharge. Interview data were supplemented with agency assessment and service use data. We did not find evidence that the CTM could predict home healthcare patients having an elevated risk for emergent care, rehospitalization, or higher home health nursing use. Because Medicare/Medicaid-certified home healthcare providers already use a comprehensive, mandated start of care assessment, the CTM may not provide them additional crucial information. Process and outcome measurement is increasingly becoming part of usual care. Selection of measures appropriate for each service setting requires thorough site-specific evaluation. In light of our findings, we cannot recommend the CTM as an additional measure in the home healthcare setting.

Migrant care workers and rehospitalization among older patients discharged from acute care hospitals

“…Older age was associated with a lower likelihood of rehospitalization, which is in keeping with the recent finding of an inverse relationship between age and the rate of rehospitalization among patients discharged from hospitals . Additionally, the finding that the use of hospital resources in the year preceding death is inversely related to the age of death could help to explain our results.…”

“…Critical health conditions, functional dependency, previous hospital admissions, longer duration of hospital stay and higher morbidity are currently considered as established risk factors for rehospitalization, whereas the association between older age and rehospitalization is not univocal. Indeed, although an increased risk of rehospitalization with advancing age has been reported, other studies showed the lack of a significant association, or even an inverse association …”

Perceived discharge quality and associations with hospital readmissions and emergency department use: a prospective cohort study

“…The CTM scores reported by the sample population (CTM-15 median 80.0 (IQR 66.6–100.0)) were high relative to the published literature, where median CTM-15 scores tend to range between 63.7 and 81.8, with between 1% and 10% of patients in these studies reporting the maximum score 23 24 29–32. In contrast, 18.0% of patients in our sample had maximum scores on the CTM-15.…”

Validity and reliability of the Japanese version of the Care Transitions Measure

“…By 8 weeks, when we conducted the present survey, some patients probably avoided visits to the emergency department or re‐hospitalizations by receiving support from outpatient services. A previous study showed that other assessment tools, aside from the J‐CTM‐15, are therefore more suitable to assess the necessity of visits to the emergency department …”

“…A previous study showed that other assessment tools, aside from the J-CTM-15, are therefore more suitable to assess the necessity of visits to the emergency department. 20,21 The J-CTM is a reliable and valid instrument for medical staff and policy makers to evaluate care transitions from the perspective of patients. The J-CTM-15 can be used as a screening tool for patients who need a high level of follow-up support.…”