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.
For more information on this article, contact Margaret McDonald at email@example.com.
Miriam Ryvicker, PhD, is a Research Associate at the Center for Home Care Policy and Research, Visiting Nurse Service of New York (VNSNY), New York City. She is responsible for designing and overseeing the implementation of research methodology on various initiatives. Her current research focuses on neighborhood environmental factors in the health and quality of life of community-dwelling older adults, especially in the context of underserved communities. She is the recipient of a Mentored Career Development Award from the National Institute on Aging.
Margaret V. McDonald, MSW, is Associate Director of Research Studies at the Center for Home Care Policy and Research, Visiting Nurse Service of New York (VNSNY), New York City. She has over 15 years of research management experience; over 10 years have been in the community-based setting operationalizing and overseeing intervention and primary data collection activities.
Melissa Trachtenberg, is a Research Analyst and Field Coordinator at the Center for Home Care Policy and Research, Visiting Nurse Service of New York (VNSNY), New York City. In her role at VNSNY, she is responsible for setting up, coordinating, and monitoring primary data collection activities.
Timothy R. Peng, PhD, is the Director of Analytics at the Center for Home Care Policy and Research, Visiting Nurse Service of New York (VNSNY), New York City. He is a statistical programming expert with extensive experience in the linking and use of clinical and administrative databases. For over a decade, he has conducted health services research on projects ranging from translational clinical interventions to secondary analysis of nationally representative claims and survey data.
Sridevi Sridharan, MS, is a Research Programmer Analyst at the Center for Home Care Policy and Research, Visiting Nurse Service of New York (VNSNY), New York City. She provides data management and analytic support across multiple projects including database development, merging of different data sources, and reporting responsibilities.
Penny H. Feldman, PhD, is Senior Vice President for Research and Evaluation at the Visiting Nurse Service of New York (VNSNY) and Director of the VNSNY Center for Home Care Policy and Research. At the Center, she directs projects focused on improving the quality and outcomes of home-based care, reducing disparities among vulnerable populations, developing supportive communities for a growing older population, and facilitating informed decision making by clinicians, managers, and policy makers.
Grant sponsor: The Commonwealth Fund; Grant Number: 20100275.