Using the Care Transitions Measure in Home Care Settings to Improve Outcomes and Reduce Hospital Readmissions


The Care Transitions Measure was developed with earlier Commonwealth Fund support to assess the adequacy of instructions that hospitals provide their patients prior to discharge. This brief questionnaire for patients will now be tested to see whether home health care agencies and other post-acute care providers can use it to: 1) assess how well a hospital prepares patients for home care; 2) predict the level of care resources new patients will require; 3) tailor services to patients' individual needs; and 4) provide hospitals with feedback on their transitional care. The project team will also develop a version of the Care Transitions Measure capable of assessing how well home health care agencies prepare their patients for discharge. The findings will aid efforts to reduce avoidable rehospitalizations and rein in spiraling costs.

Grant Details

Grantee Organization:
Visiting Nurse Service of New York
Principal Investigator:
Penny Hollander Feldman, Ph.D.
Award Amount:
Approval Date:
April 13, 2010
Related Topics
Health Care Delivery

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