The IssueThe Care Transitions Measure (CTM) was developed to assess the continuity and quality of care provided to patients who are being transferred from one health care setting to another—such as from hospital to home, nursing home, or rehabilitation facility. In a Commonwealth Fund–supported study conducted at a community nonprofit hospital, researchers examined the CTM’s ability to identify deficiencies in transitional care for older patients being discharged, as well as to measure the impact of subsequent quality improvement measures.
What the Study Found
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.