Table 6.

Five Transitional Care Strategy Groups in Prospective Analysis and Requisite Strategies

TC Strategy Groups and Patients Exposed	Required TC Strategies a	Methodological Steps Informing Group Membership
Patient Communication and Care Management (n = 2158, 27.2%)	• Patient Goal/Preference Assessment • Plain Language Communication at Hospital • Transition Summary for Patients and Caregivers • Helpful Health Care Contact OR Symptom Management • Plain Language Communication at Home • Post-Discharge Care Consultation	• Original retrospective group (Care Plan) • Factor analysis • Latent class analysis • Expert opinion
Hospital-Based Trust, Plain Language, and Coordination (n = 2090, 26.3%)	• Identify High-Risk Patients and Intervene • Plain Language Communication at Hospital • Promote Trust in the Hospital (care and concern expressed to patients, rapport building in the hospital) • Medication Reconciliation • Transition Summary for Patients and Caregivers • Post-Discharge Care Consultation	• Original retrospective group (Medication Reconciliation; Care Plan) • Factor analysis • Latent class analysis • Finite mixture model • Expert opinion
Home-Based Trust, Plain Language, and Coordination (n = 1979, 24.9%)	• Transition Team • Follow-up Appointment • Referral to Community Services • Home Visits • Promote Trust at Home (care and concern expressed to patients, rapport building post-discharge) • Plain Language Communication at Home	• Original retrospective group (Identify High Risk) • Latent class analysis • Finite mixture model • Expert opinion
Patient/Family Caregiver Assessment and Information Exchange among Providers (n = 3093, 39%)	• Identify High-Risk Patients and Intervene • Patient/Family Caregiver Transitional Care Needs Assessment • Patient Goal/Preference Assessment • Timely Exchange of Critical Patient Information among Providers	• Original retrospective group (Cross-Setting Information Exchange) • Factor analysis • Latent class analysis • Expert opinion
Assessment and Teach Back (n = 508, 6.4%)	• Language Assessment • Teach Back for Information and Skills • Post-Discharge Care Consultation	• Factor analysis • Latent class analysis • Finite mixture model • Expert opinion
No TC Groupb (n = 2042, 25.7%)	• Not in any other group	• Original retrospective group (No TC Group)

Note: N refers to number of patients exposed to each group; Patients may be exposed to more than one group

TC strategies throughout the tables are ordered alphabetically by care setting (e.g., first hospital-based, then bridging, then home-based

^a Due to their near universal application, Identification of Caregiver, Interdisciplinary Approach, and Standard Protocols are presumed to be a part of each TC group.^b Patients were exposed to other TC strategies, but not in the groups defined above