transition to home. Researchers from the University of Colorado Health Sciences Center developed the CTM with an explicit and unique focus on the care transition experience (Coleman et al., 2004d). The CTM can be administered either as a 15-item and a 3-item (subset) measure, both of which have been shown to discriminate among hospitals and predict rehospitalization or return to the emergency department.
The focus of the third bucket is on outcomes, usually in the form of utilization of or recidivism to high-intensity health care services such as the hospital or emergency department. To date, this strategy has been the least developed. One approach, developed in the Medicare Current Beneficiary Survey, defines complicated care transitions as an interruption in the movement from higher intensity care settings (where there is presumably greater functional dependency and medical instability) to lower intensity care settings (Coleman et al., 2004a).
The fourth bucket includes accreditation measures, such as those used by JCAHO. The relevant JCAHO activities that pertain to transitional care are discussed in greater detail in the following section.
There are other potential approaches to assessing quality in this area that either do not fit into one of the buckets above or have not yet been attempted, for example, the completion or updating of an adult patient’s Personal Health Record (ASTM International et al., 2003) or information to support a child’s Medical Home within pediatric care (American Academy of Pediatrics, 2003). Inclusion of a completed Physician Orders for Life-Sustaining Treatment (Oregon Health and Science University, 1996) in the transfer information that accompanies a patient across settings could be converted into a measurement activity. Areas addressed may include: resuscitation, medical interventions, antibiotic usage, artificially administered fluids, and nutrition. Finally, a number of measures have been developed to assess the transition from pediatric to adult medical providers among teenagers (Reiss and Gibson, 2002).
CMS currently reimburses clinicians for a number of care coordination and care oversight activities that, if modified, could serve as a template for more formal performance measurement for transitional care. For example, Care Plan Oversight (CPT code 99374 for home health care) involves physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including phone calls) for purposes of assessment or care decisions with health care professionals, family members, surrogate decision makers, and/or key caregivers involved in patient’s care, integration of new information into the medical treatment plan, and/or adjustment of medical therapy within a calendar month. In addition, Discharge Day Management (CPT code 99238 if <30 minutes or 99239 if >30 minutes) includes final examination, discussion of hospital stay, instructions for con-