Can the care transitions measure predict rehospitalization risk or home health nursing use of home healthcare patients?

J Healthc Qual. 2013 Sep-Oct;35(5):32-40. doi: 10.1111/jhq.12023.


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.

Keywords: Care Transitions Measure; home healthcare; performance measurement; rehospitalization; service utilization.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Female
  • Home Care Services / statistics & numerical data*
  • Humans
  • Logistic Models
  • Male
  • Patient Readmission*
  • Patient Transfer / standards*
  • Qualitative Research
  • Risk Assessment / methods
  • United States