Understanding the groups of care transition strategies used by U.S. hospitals: an application of factor analytic and latent class methods

Glen Mays, Jing Li, Jessica Miller Clouser, Gaixin Du, Arnold Stromberg, Brian Jack, Huong Q. Nguyen, Mark V. Williams

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


Background: After activation of the Hospital Readmission Reduction Program (HRRP) in 2012, hospitals nationwide experimented broadly with the implementation of Transitional Care (TC) strategies to reduce hospital readmissions. Although numerous evidence-based TC models exist, they are often adapted to local contexts, rendering large-scale evaluation difficult. Little systematic evidence exists about prevailing implementation patterns of TC strategies among hospitals, nor which strategies in which combinations are most effective at improving patient outcomes. We aimed to identify and define combinations of TC strategies, or groups of transitional care activities, implemented among a large and diverse cohort of U.S. hospitals, with the ultimate goal of evaluating their comparative effectiveness. Methods: We collected implementation data for 13 TC strategies through a nationwide, web-based survey of representatives from short-term acute-care and critical access hospitals (N = 370) and obtained Medicare claims data for patients discharged from participating hospitals. TC strategies were grouped separately through factor analysis and latent class analysis. Results: We observed 348 variations in how hospitals implemented 13 TC strategies, highlighting the diversity of hospitals’ TC strategy implementation. Factor analysis resulted in five overlapping groups of TC strategies, including those characterized by 1) medication reconciliation, 2) shared decision making, 3) identifying high risk patients, 4) care plan, and 5) cross-setting information exchange. We determined that the groups suggested by factor analysis results provided a more logical grouping. Further, groups of TC strategies based on factor analysis performed better than the ones based on latent class analysis in detecting differences in 30-day readmission trends. Conclusions: U.S. hospitals uniquely combine TC strategies in ways that require further evaluation. Factor analysis provides a logical method for grouping such strategies for comparative effectiveness analysis when the groups are dependent. Our findings provide hospitals and health systems 1) information about what groups of TC strategies are commonly being implemented by hospitals, 2) strengths associated with the factor analysis approach for classifying these groups, and ultimately, 3) information upon which comparative effectiveness trials can be designed. Our results further reveal promising targets for comparative effectiveness analyses, including groups incorporating cross-setting information exchange.

Original languageEnglish
Article number228
JournalBMC Medical Research Methodology
Issue number1
StatePublished - Dec 2021

Bibliographical note

Funding Information:
Hospital discharge represents a critical and vulnerable point in the continuum of patient care. As patients transition from hospitals to home or other sites of care, they face myriad challenges arising from a lack of clarity surrounding who is responsible for their care, confusion around complex care plans [], and often poor communication among health care providers. Unplanned hospital readmissions serve as a marker for poor care transitions resulting in diminished patient satisfaction, increased risk of hospital-acquired infection, and elevated healthcare costs [, ]. In an effort to improve the provision of healthcare for Americans, the Hospital Readmission Reduction Program (HRRP) [], part of the Affordable Care Act, was passed into law in 2010 and activated in 2012. The HRRP reduces payments to hospitals with excess readmissions. As a result, the past decade has seen billions of dollars invested in quality improvement initiatives and value-based payment incentives to improve care transitions and reduce hospital readmissions [, ]. Such initiatives include organized transitional care (TC) programs supported by the U.S. Centers for Medicare and Medicaid Services (CMS), including the Hospital Engagement Networks (HENs) []—later becoming Healthcare Improvement Innovation Networks (HIINs)— the Quality Improvement Organizations’ Integrating Care for Populations and Communities (QIO ICPC) Aim and the Community-based Care Transitions Programs (CCTPs) [].

Funding Information:
Authors acknowledge the assistance of Health Research and Education Trust (HRET), America?s Essential Hospitals (AEH), and Joint Commission Resources (JCR) in distributing the hospital survey among their membership. We also appreciate the assistance provided by other ACHIEVE Investigators and advisors for their input and feedback.

Publisher Copyright:
© 2021, The Author(s).


  • Comparative effectiveness research
  • Evidence-based practice
  • Health care
  • Readmission reduction
  • Transitional care

ASJC Scopus subject areas

  • Epidemiology
  • Health Informatics


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