This chapter provides information comparing evaluation to performance measurement, the importance of planning ahead; types of care transitions measures; process and structural measures;  health care utilization measures; clinical and functional status; satisfaction with services measures; health literacy, consumer understanding, and empowerment; measuring the value of connection to LTSS within care transitions programs; access and connection to LTSS; caregiver and social supports; community living; and quality of life. ADRCs can leverage ARP funds to start or bolster care transitions programs in the context of vaccine access. Measuring the success of these efforts will be key in long-term sustainability.

Additional Resources

• Care Transitions September Hospital2Home Webinar
• ACL’s Center for Policy and Evaluation
• Iowa Progress Report on the Pilot Initiative to Provide Long-Term Care Options Counseling – Iowa Return To Community
• National Core Indicators
• National Core Indicators – Aging and Disabilities (NCI-AD)
• National Quality Forum Home and Community Based Measures Conceptual Framework Initiative
• Agency for Healthcare Research and Quality (AHRQ) Quality and Patient Safety Resources
• All-Payer Claims Databases Measurement of Care: Systematic Review and Environmental Scan of Current Practices and Evidence
• Tools for Quality Measurement: CAHPS®
• AHRQ Key Questions When Choosing Health Care Quality Measures  
• AHRQ Measures of Quality for Different Health Care Settings
• The National Center for Complex Health & Social Needs & the Institute for Healthcare Improvement “Measuring complexity: Moving toward standardized quality measures for the field of complex care”
• CMS Measures Inventory Tool

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