Resource Utilization Groups in transitional home care: validating the RUG-III/HC case-mix system in hospital-to-home care programs

BACKGROUND: Transitional hospital-to-home care programs support safe and timely transition from acute care settings back into the community. Case-mix systems that classify transitional care clients into groups based on their resource utilization can assist with care planning, calculating reimbursement rates in bundled care funding models, and predicting health human resource needs. This study evaluated the fit and relevance of the Resource Utilization Groups version III for Home Care (RUG-III/HC) case-mix classification system in transitional care programs in Ontario, Canada. METHODS: We conducted a retrospective analysis of clinical assessment data and administrative billing records from a cohort of clients (n = 1,680 care episodes) in transitional home care programs in Ontario. We classified care episodes into established RUG-III/HC groups based on clients’ clinical and functional characteristics and calculated four case-mix indices to describe care relative resource utilization in the study sample. Using these indices in linear regression models, we evaluated the degree to which the RUG-III/HC system can be used to predict care resource utilization. RESULTS: A majority of transitional home care clients are classified as being Clinically complex (41.6%) and having Reduced physical functions (37.8%). The RUG-III/HC groups that account for the largest share of clients are those with the lowest hierarchical ranking, indicating low Activities of Daily Living limitations but a range of Instrumental Activities of Daily Living limitations. There is notable heterogeneity in the distribution of clients in RUG-III/HC groups across transitional care programs. The case-mix indices reflect decreasing hierarchical resource use within but not across RUG-III/HC categories. The RUG-III/HC predicts 23.34% of the variance in resource utilization of combined paid and unpaid care time. CONCLUSIONS: The distribution of clients across RUG-III/HC groups in transitional home care programs is remarkably different from clients in long-stay home care settings. Transitional care programs have a higher proportion of Clinically complex clients and a lower proportion of clients with Reduced physical function. This study contributes to the development of a case-mix system for clients in transitional home care programs which can be used by care managers to inform planning, costing, and resource allocation in these programs. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12913-023-10150-1.