"The greatest opportunities for improving care transitions center around improving communication, building cross-setting relationships, and redesigning our workflow."
~ Eric A. Coleman, MD, MPH

With support from The Commonwealth Fund, The Robert Wood Johnson Foundation, and the Paul Beeson Faculty Scholars in Aging, Dr. Coleman and colleagues designed a 15-item uni-dimensional measure, the Care Transitions Measure (CTM®), to assess the quality of care transitions. The primary objective of this endeavor has been to develop a measure that is both substantively and methodologically consistent with the concept of patient-centeredness, and useful for the purpose of performance measurement and subsequent public reporting.

Psychometric testing of the CTM® has been completed, demonstrating high internal consistency, reliability. and applicability for assessment across multiple sites of care (i.e., hospital to home, hospital to skilled nursing facility, skilled nursing facility to home, etc.). The measure also demonstrated the power to discriminate between: 1) patients discharged from the hospital who did/did not experience a subsequent emergency visit or rehospitalization for their index condition, and 2) health care facilities with differing levels of commitment to care coordination.

While the testing of the CTM® was done using a post-hospitalization model, this measure is applicable to a variety of settings, including skilled nursing facilities, rehabilitation, and other locations patients are likely to utilize during transition.

Tool Kit Components


The Care Transitions Intervention® and all of its materials are the property of the Care Transitions Program®. The Care Transitions Program® is solely authorized to provide training on the Care Transitions Intervention®. If another entity offers to train your organization, please contact us.


© Eric A. Coleman, MD, MPH