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Session Details

This IHI Virtual Expedition is designed to support hospital-based teams and their community partners in co-designing and reliably implementing improved care processes to ensure that patients who have been discharged from the hospital have an ideal transition home or to the next community care setting.

The transition from the hospital to post-acute care settings has emerged as an important priority in the Institute for Healthcare Improvement's (IHI’s) work to reduce avoidable rehospitalizations. Transitions in care after a hospitalization involve both an improved transition out of the hospital (and from post-acute care and rehabilitation facilities) as well as an activated (ready for specified transitions process) and reliable reception into the next setting of care such as a primary care practice, skilled nursing facility, or home care. 

This Expedition will also cover strategies to reduce rehospitalizations as poor coordination of care across settings too often results in avoidable readmissions. Hear from experts in the field who are redesigning care to include the application of new program designs and thinking disruptively. What if patients are engaged to provide their own self-care at home in the administration of outpatient parenteral antimicrobial therapy? Hear the results when activated patients support their care at home, maintaining their life with minimal disruption while healing. Enroll now.


At the end of the Expedition each participant will be able to:
  • Identify reliable and effective models of care transitions from a hospital admission to post-acute care.
  • Develop processes with post-acute care providers and community partners to ensure the timely transfer of critical information during transitions.
  • Build an effective improvement team including patients and families as well as acute, post-acute and community care partners
  • Identify successful approaches in identifying clinical-community linkages to make an ideal individualized person centered transition of care plan. 
  • Identify key issues and strategies related to readmissions for racial and ethnically diverse patients
  • Engage participants in sharing strategies and innovative thinking to explore real life issues related to transitions.
  • Discuss disruptive innovations and models that support patients to provide effective self-care at home. 

This IHI Virtual Expedition is approved for a maximum of  6 continuing education credits  for physicians and nurses.


Session 1: Building the Will, Ideas and Execution for Successful Transitions
Date: April 27, 2017
Time: 1:00 PM–2:30 PM ET

Session 2: Leveraging the Expertise of Direct-Care Staff to Reduce Hospital Readmissions: Project RED, Re-Engineered Discharge 
Date: May 11, 2017 
Time: 1:00 PM–2:00 PM ET

Session 3: Achieving Equity: Readmissions and Real World Lessons
Date: May 25, 2017 
Time: 1:00 PM–2:00 PM ET

Session 4: Building Partnerships to Establish a Post-Acute Preferred Provider Network
Date: June 8, 2017 
Time: 1:00 PM–2:00 PM ET

Session 5: Disruptive Innovations in Self Care and Health Equity
Date: June 22, 2017 
Time: 1:00 PM–2:30 PM ET ​


Bradke Peg1.jpgPeg M. Bradke, RN, MA, Vice President of Post-Acute Care at UnityPoint-Cedar Rapids, Iowa, St. Luke's, oversees a long-term acute care hospital and two skilled nursing and intermediate care facilities, with responsibility for home care, hospice, palliative care, and home medical equipment. She serves as the executive sponsor for the Population Health and Care Coordination work in her region. In her 25-year career in heart care services, Ms. Bradke has held vaState administrative positions. In her previous role as Director of Heart Care Services at St. Luke's, she managed two intensive care units, two step-down telemetry units, several cardiac-related labs, and heart failure and Coumadin clinics. Ms. Bradke also served as faculty for the Inst​​itute for Healthcare Improvement on the Transforming Care at the Bedside (TCAB) initiative and the STAAR (State Action on Avoidable Rehospitalizations) initiative. She is Senior Leader for the Practice Change Leaders Program.  

Sue Gullo Pic.jpgSue Leavitt Gullo, RN, BSN, MS, Director, Institute for Healthcare Improvement, brings 35 years of health care experience to IHI, focusing for the past 10 years on leading and directing organizations across multiple improvement work streams. Her areas of expertise include maternal and child h ealth, patient safety, and leadership. Working at the country level with senior leaders in nongovernmental organizations and hospital systems, Ms. Gullo has been the Senior Director in the field to execute projects, provide translational leadership, and coach and support frontline teams and consumers of health care. She has led the IHI Perinatal Community since its inception in 2004 and is co-lead for IHI's maternal and infant health priority area. Ms. Gullo was elected to the Association of Women’s Health, Obstetrical, and Neonatal Nursing Board of Directors in 2014 and is also a member of other national mat ernal-child health advisory committees. Previously, she was Director of Women’s Services at Elliot Hospital in Manchester, New Hampshire, and she spent 25 years at the front line of health care delivery as an oncology and medical-surgical nurse.