J Korean Med Sci.  2023 Aug;38(32):e246. 10.3346/jkms.2023.38.e246.

Development of Items for Transitional Care Service and Outcome Indicators of Discharged Patients for Improvement in Quality of Care

  • 1Department of Health Policy and Management, School of Medicine, Kangwon National University, Chuncheon, Korea
  • 2Department of Preventive Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
  • 3Department of Preventive Medicine, University of Ulsan College of Medicine, Seoul, Korea


In this study, with the aim of improving the quality of transitional care service for discharged patients, the Health Care Quality and Outcomes Indicators of the Organization for Economic Co-operation and Development and National Health Service Outcomes Framework of the UK were applied to derive service items for provision and develop evaluation indicators under categories of effectiveness, safety, and patient-centeredness. Method: A scoping review was conducted to derive core concepts and evidence materials/data for transitional care service. For the derived items of transitional care service and evaluation indicators, a three-round Delphi study was conducted with experts in the fields of healthcare/ medicine/nursing/social welfare.
First, as a result of the scoping review, components of transitional care service (assessment of need by period of transitional care service, multi-professional team, connection to community resources, etc.) and themes for outcome indicators (effectiveness, patient safety, patient-centeredness) were derived. Second, by classifying the items for assessment according to the hospitalization and transition period and conducting a Delphi study to derive service items for transitional care service, during the hospitalization period, presence/absence of a caregiver and need for a caregiver, activities of daily living, and necessity for home-based care services were identified as items of high priority. Regarding patient safety, risk of falls and fractures during hospitalization, and necessity for medication reconciliation were identified as the items of high importance. For the transition period, provision of education regarding adequate responses and handling of emergencies, provision of information and guidance on application of services for basic livelihood security program beneficiaries, and education for patient skills in self-management of health were derived as items of high priority. Third, for the derivation of outcome indicators for transitional care service, in the “effectiveness” category, the experts rated a reduction in the 30-day readmission rate as an item of high importance along with a decrease in emergency department visits, reduction in preventable admissions as indicators of high relevance. In terms of “patient safety,” a decrease in drug adverse reactions, and reduction in the incidence of falls and pressure ulcers were identified as indicators of high priority. Finally, for the category of “patient-centeredness,” patient experience assessment, level of service satisfaction reported by patients and their caregivers, and reducing burden on caregivers were identified as indicators of high priority.
This study suggest practical implications for the service with high relevance and necessity for transitional period. It also presented outcome indicators of transitional care service to contribute toward an improvement in the quality of care.


Patient-Centeredness; Transitional Care; Evaluation Indicators; Priority; Delphi


  • Fig. 1 Methods flowchart.TCS = transitional care service, OECD = Organization for Economic Co-operation and Development.

  • Fig. 2 Equation for calculation of CVR.CVR = content validity ratio.

  • Fig. 3 Concept map of the transitional care pooled from the literature.COPD = chronic obstructive pulmonary disease, QOL = quality of life.

  • Fig. 4 Third-round Delphi study: Items to be assessed for hospitalization period/transition period.

  • Fig. 5 Third-round Delphi study: TCS evaluation indicators.TCS = transitional care service.


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