Baseline CTM scores suggested the need for improvement in a number of areas. These deficiencies were translated into a set of three clinical care goals: 1) attention to how a patient’s illness would affect them when they returned home; 2) helping patients understand how to properly self-administer medication and monitor for adverse effects; and 3) providing comprehensive written discharge instructions. CTM scores increased significantly when interventions were implemented to address these clinical goals, although these gains were counteracted by unrelated systemwide changes at the hospital that occurred simultaneously.
CTM scores also significantly predicted patients’ return to the emergency department within 30 days of discharge.
CTM scores are responsive to both positive and negative influences on transitional care. The brief, patient-centered CTM is a useful and important tool for assessing both transitional care performance and the impact of quality improvement measures.