Table 2.
Transitional Care Process Site Scores
| Site | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | AV (Range) | # Facilities scored 3 | # Facilities scored 0 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Process Name | Site Score | ||||||||||||
| Pre-discharge patient education | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 10 | 0 |
| Medication reconciliation prior to discharge | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 10 | 0 |
| Implementation of discharge planning rounds | 3 | 1 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 2.8 (1–3) | 9 | 0 |
| Assignment of medication reconciliation to pharmacist | 0 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 2 | 3 | 2.6 (0–3) | 8 | 1 |
| Enlisting social and community supports (home health services, Meals-on-Wheels, day care services, housing, etc.) for post-discharge care | 2 | 1 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 2.7 (1–3) | 8 | 0 |
| Printed follow-up instructions which might include medication reconciliation, follow-up appointments, self-care tasks or action plan for management of symptoms | 2 | 3 | 2 | 2 | 3 | 3 | 2 | 2 | 3 | 2 | 2.4 (2–3) | 5 | 0 |
| Post-discharge phone call from PACT team | 1 | 3 | 3 | 3 | 1 | 3 | 3 | 1 | 2 | 2 | 2.2 (1–3) | 5 | 0 |
| Implementation of a discharge checklist | 0 | 1 | 1 | 3 | 3 | 3 | 1 | 3 | 3 | 0 | 1.8 (0–3) | 5 | 2 |
| Utilization of discharge/care transitions case manager | 2 | 3 | 1 | 3 | 3 | 2 | 2 | 2 | 2 | 3 | 2.3 (1–3) | 4 | 0 |
| Post discharge follow-up appointments to PCP and for diagnostic testing made prior to discharge | 1 | 1 | 2 | 3 | 3 | 1 | 0 | 1 | 3 | 1 | 1.6 (0–3) | 3 | 1 |
| Direct communication with PCP or other PACT team members | 1 | 3 | 2 | 2 | 2 | 2 | 3 | 3 | 2 | 2 | 2.2 (1–3) | 3 | 0 |
| Need for rehabilitation services routinely assessed during discharge planning | 3 | 1 | 1 | 3 | 3 | 2 | 2 | 1 | 2 | 2 | 2.0 (1–3) | 3 | 0 |
| Increased emphasis on patient education about diagnoses, self-management and medications throughout hospitalization | 0 | 1 | 0 | 0 | 1 | 0 | 2 | 3 | 1 | 1 | .7 (0–3) | 1 | 4 |
| Assessment for advance care planning (palliative / hospice) | 1 | 1 | 2 | 1 | 1 | 1 | 2 | 1 | 3 | 1 | 1.4 (1–3) | 1 | 0 |
| Post-discharge patient hotline available? | 0 | 2 | 2 | 2 | 3 | 2 | 2 | 2 | 2 | 2 | 1.9 (0–3) | 1 | 1 |
| Post-discharge home visit available? | 0 | 2 | 2 | 0 | 0 | 0 | 0 | 3 | 1 | 2 | 1.0 (0–3) | 1 | 5 |
| Post-discharge phone call from hospital (who, time frame) | 0 | 0 | 0 | 2 | 3 | 0 | 1 | 0 | 0 | 2 | 0.8 (0–3) | 1 | 6 |
| Communication of medical plans in front of patients during physician team rounds | 0 | 2 | 2 | 0 | 2 | 2 | 2 | 2 | 2 | 2 | 1.6 (0–2) | 0 | 2 |
| Use of teach-back method with patients | 2 | 2 | 1 | 2 | 2 | 1 | 2 | 1 | 2 | 2 | 1.7 (1–2) | 0 | 0 |
| Assessment of readmission risk | 0 | 0 | 1 | 1 | 2 | 0 | 0 | 0 | 0 | 0 | 0.4 (0–2) | 0 | 7 |
| Summary Score | 24 | 36 | 37 | 42 | 47 | 37 | 39 | 40 | 42 | 39 | 38.3 (24–47) | ||
| Best Fit Predicted RSRR | 16.1 | 15.2 | 14.7 | 12.8 | 13.0 | 14.1 | 11.9 | 13.1 | 11.8 | 12.9 | |||