Opening Pandora’s Box

Abstract

Background: Measuring the effectiveness of transitional care interventions has historically relied on health care utilization as the primary outcome. Although the Care Transitions Measure was the first outcome measure specifically developed for transitional care, its applicability beyond the hospital-to-home transition is limited. There is a need for patient-centered outcome measures (PCOMs) to be developed for transitional care settings (ie, TC-PCOMs) to ensure that outcomes are both meaningful to patients and relevant to the particular care transition. The overall objective of this paper is to describe the opportunities and challenges of integrating TC-PCOMs into research and practice. Methods and Results: This narrative review was conducted by members of the Patient-Centered Outcomes Research Institute (PCORI) Transitional Care Evidence to Action Network. We define TC-PCOMs as outcomes that matter to patients because they account for their individual experiences, concerns, preferences, needs, and values during the transition period. The cardinal features of TC-PCOMs should be that they are developed following direct input from patients and stakeholders and reflect their lived experience during the transition in question. Although few TC-PCOMs are currently available, existing patient-reported outcome measures could be adapted to become TC-PCOMs if they incorporated input from patients and stakeholders and are validated for the relevant care transition. Conclusion: Establishing validated TC-PCOMs is crucial for measuring the responsiveness of transitional care interventions and optimizing care that is meaningful to patients.

Care Transition Interventions to Improve Stroke Outcomes: Evidence Gaps in Underserved and Minority Populations

“…Also by only focusing on readmissions we fail to acknowledge the wide range of other patient experiences that occur during care transitions which include practical, economic, psychosocial and mental health concerns. 70 However, there is now a growing number of intervention studies conducted in stroke patients or caregivers that address transitional care challenges more broadly, and do not rely solely on readmissions as a measure of success. These include the use of post-acute multidisciplinary care teams, 71 early supported discharge programs, 72 tailored hospital discharge planning, 73 enhanced patient or caregiver education and information, 33,74 self-management support or skill development, [75][76][77] and care management programs that rely on care navigators or other patient advocates (including social workers, 78 nurses, 79 peer mentors, 80 and community health workers 81,82 ).…”

“…69 The limitations of using hospital readmissions as the primary marker of success for transition-based intervention studies has been noted previously. 70 Readmissions occur due to a multitude of complex factors that are usually beyond the direct control of the provider or patient. Also by only focusing on readmissions we fail to acknowledge the wide range of other patient experiences that occur during care transitions which include practical, economic, psychosocial and mental health concerns.…”

Stroke Care Costs and Cost-Effectiveness to Inform Health Policy

“…13 The greatest limitation of these evaluations to date is the lack of available patient-reported outcome measures. Although more stroke services are measuring patient-reported outcomes, 14,15 more countries and regions could be using these in conjunction with health service use data to guide payment and policy reform.…”

Development and validation of the Care Transitions Scale for Patients with Heart Failure: A tool for nurses to assess patients' readiness for hospital discharge

“…These self-evaluation scales are valuable instruments. Moreover, in recent years, the use of patient-centered indicators such as "medical staff-reported assessments from patients' perspectives" and "patient-reported outcome measures" has attracted attention (Reeves et al, 2021). Thus, we consider that it would be necessary to develop a new patient-centered scale to assess patients' readiness for hospital discharge, as the aim is to assess transitional care for individual patients and not evaluate general nursing practice.…”