How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations

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How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations

Last Modified: 06/07/2012

Institute for Healthcare Improvement

Cambridge, Massachusetts, USA

How to cite this document:

Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2012. Available at www.IHI.org.

This How-to Guide is designed to support hospital-based teams and their community partners in codesigning and reliably implementing improved care processes to ensure that patients who have been discharged from the hospital have an ideal transition to the next setting of care (such as a primary care practice, home care, or a skilled nursing facility).

The Guide includes:

Getting Started: This section lists steps to get started on creating an ideal transition for patients being discharged from the hospital, a post-acute care setting, or a rehabilitation facility.
Key Changes: Four key recommendations for improving the transition out of the hospital are described, including typical failures encountered, recommended measures to guide improvement, and tools and resources to help teams implement the changes.
Infrastructure and Strategy to Achieve Results: A review of the necessary leadership support and fundamental improvement methods and resources for testing changes before they are implemented and spread more widely throughout the organization.
Case Studies: The cases provide examples of how organizations implemented the key changes to improve transitions from the hospital.
Measures, Resources, and References: Worksheets and other tools to help hospital teams implement the changes, along with a bibliography of selected resources.

Background

This guide was developed as part of the STate Action on Avoidable Rehospitalizations (STAAR) initiative.

Documents

How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations

How-to Guide: Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations
This How-to Guide focuses on the reception of patients back into the office practice after hospitalization and is intended to be a resource for clinicians and staff in office practices as they create new ways to provide optimal care for their patients.
How-to Guide: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations
This guide focuses on the transfer of patients to skilled nursing facilities (SNFs), an umbrella term that includes nursing homes, long-term care facilities, acute rehabilitation facilities, and post-acute care facilities.
How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations
This How-to Guide is designed to support hospital-based teams and their community partners in creating an ideal reception into home health care in the first 48 hours after the patient is discharged from the hospital, a post-acute care setting, or a rehabilitation facility.

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