Care Transitions Measure
Care Transitions Measure (CTM-3) · Also known as: CTM-3, Transition Quality Measure
The Care Transitions Measure (CTM-3) is a three-item patient-reported outcome instrument that assesses how well patients feel prepared for the transition from one care setting to another—for example, from hospital to home, from acute care to rehabilitation, or from hospital to primary care. Developed by Carla Parry and colleagues in 2008, the CTM-3 measures whether patients received adequate preparation for self-care, understood their care plan, and felt supported in managing their transition. The measure is widely used to evaluate care coordination and transition planning quality, and has become a standard metric in quality improvement and research on hospital discharge and continuity of care.
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When to use it
The CTM-3 is administered 2-4 weeks after a care transition to assess the quality of preparation and support for that specific transition. It is appropriate for patients transitioning from hospital to home, from acute care to rehabilitation, from one facility to another, or from inpatient to primary care. Used in quality improvement programs, readmission reduction initiatives, and research evaluating transition interventions. Suitable for adult patients with cognitive and literacy capacity to reflect on their transition experience.
Strengths & limitations
- Brevity and ease of administration: only three items, <2 minutes, can be completed by phone, mail, or digital platform; low respondent burden increases completion rates.
- Sensitive to intervention: CTM-3 scores improve with well-designed transition interventions (e.g., discharge coaching, care coordinator follow-up, primary care engagement); responsive to change.
- Predictive of readmission: low CTM-3 scores are associated with higher 30-day and 60-day readmission rates; can serve as a risk stratification tool.
- Actionable item-level insight: each of the three items maps to a specific transition preparation element (self-care knowledge, medication understanding, care team support), enabling targeted improvement.
- Alignment with national quality initiatives: widely used in readmission reduction programs, shared savings models, and accountable care organization quality metrics.
- Limited depth: three items cannot capture all dimensions of transition quality; ancillary measures (clinician documentation review, readmission rates, medication errors) are needed for comprehensive assessment.
- Recall and response bias: patient may have difficulty recalling transition details weeks later; satisfaction with post-transition outcomes may color perception of preparation quality.
- Does not capture transition type variation: patient transferring from hospital to skilled nursing facility has different transition needs than one going home alone; a single score may not reflect context-specific adequacy.
- No severity distinction: CTM-3 does not differentiate between mild and severe transition problems; qualitative follow-up interviews may be needed to understand root causes of low scores.
- Outcome measurement required: CTM-3 measures process (preparation) but not outcomes; readmission, emergency visits, or health status change require separate measurement to evaluate intervention impact.
Frequently asked
What score should I target for my organization?
National data suggest average CTM-3 scores (0-100 scale) around 65-70%. Best-practice organizations achieve 80%+. Set an initial improvement target of 75%, then move toward 85% as baseline performance improves. Improvement of 10-15 points per year is achievable with focused interventions.
Can CTM-3 predict which patients will be readmitted?
Low CTM-3 scores are associated with elevated readmission risk, but are not strong predictors on their own. CTM-3 combined with other risk factors (age, comorbidities, prior hospitalizations) improves prediction. Use CTM-3 as one element of a risk stratification strategy, not as a standalone predictor.
How do I improve low CTM-3 scores?
Identify which item is lowest (self-care knowledge, medication understanding, or care team support). Implement targeted interventions: for low 'self-care knowledge,' add a discharge coach or structured education; for low 'care team support,' ensure primary care appointment is scheduled before discharge and patient receives contact information.
Can CTM-3 be used for internal transfers within the hospital?
CTM-3 is designed for transitions between care settings (hospital-to-home, hospital-to-rehab). For internal transfers (ICU to medical floor), the measure may not apply as well since the patient remains in the same facility with continuous provider relationships. Use other coordination measures for internal transitions.
How do I handle patients who don't respond to CTM-3?
Aim for >=60% response rate. For non-responders, attempt phone follow-up; patients who refuse may represent dissatisfied transitions. Report response rate alongside scores; low response rate biases results upward. Consider incentives or multiple contact methods to improve response.
Sources
- Parry, C., Wolcott, J., Chuo, J., & Seasock, K. (2008). Care Transitions Measure: the development and testing of a measure designed to assess adequacy of preparation for patients transitioning between levels of care. Journal of Clinical Outcomes Management, 15(8), 417-423. link ↗
- Coleman, E. A., et al. (2009). Orienting patients and caregivers to aspects of hospital to home transition through the Care Transitions Intervention. Journal of the American Geriatrics Society, 57(7), 1337-1343. link ↗
How to cite this page
ScholarGate. (2026, June 3). Care Transitions Measure (CTM-3). ScholarGate. https://scholargate.app/en/patient-centered-care/care-transitions-measure
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