Defining the evidence-based components of transitional care interventions and using the taxonomy with systematic measurement to support improvements in quality and health

Transitional Care (TC) is recognized as one of the top priorities for health system redesign and improvement because of the potential to improve continuity and coordination across settings, providers and services. Despite support for widespread adoption and performance improvement, and the 27 direct references to TC in the Patient Protection and Affordable Care Act, translation of the evidence is moving slowly. In an effort to advance both science and practice, this paper presents a taxonomy for TC, an essential element of care coordination models. Guidance is provided for how the taxonomy can be used to complement performance measurement, identify opportunities for improvement, and guide quality initiatives that result in better patient and health system outcomes following an acute hospitalization.

Using Donabedian's framework of structure, process, and outcome, a systematic review of the literature was conducted to develop a taxonomy for TC. Since few TC interventions tested in the U.S. produced positive outcomes, the review was expanded to include U.S.-based care coordination models that support patient transitions. The structure of TC is depicted in the taxonomy by several subdomains including the type of model, recipient of the intervention, and facilitator delivering the intervention. Key and common processes including the method of recipient-to-facilitator contact, and the intensity, dose and complexity of the intervention collectively describe the process. The most common outcomes are categorized. In constructing this taxonomy and integrating it with nationally developed performance measures, several gaps in the evidence became evident. Little is actually known about how the different components work together both in the presence of a larger effort to coordinate care or when focused solely on acute to community transitions. This creates a unique opportunity to use the taxonomy to leverage the variation across model types and the gaps in evidence as targeted areas for quality improvement “small tests of change” at different phases of the transition: acute care, discharge planning, first day home, adjustment at home, coordination of services, and community reintegration. A discussion on the application of this taxonomy and the need for systematic measurement will illustrate several areas for targeted quality improvement and the opportunity to generative evidence in practice. Rigorous study of the implementation and improvement of initiatives supporting patient transitions back to the community will be a significant contribution to TC, improvement and implementation science and ultimately to the health of our nation's population and health care system.