Institute for Healthcare Improvement
Cambridge, Massachusetts, USA
How to cite this document:
Herndon L, Bones C, Bradke P, Rutherford P. How-to Guide: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at www.IHI.org.
This How-to Guide supports teams in skilled nursing facilities (SNFs) and their community partners in codesigning and reliably implementing improved care processes to ensure that residents have a safe, effective transition into — and are actively received by — the SNF (an umbrella term representing different types of post-acute care settings, including nursing homes, skilled nursing care centers, long-term care facilities, rehabilitation facilities, post-acute care facilities, and complex or convalescent care centers in Canada).
The Guide includes:
- Key Changes: Three key recommendations for improving the transition into the SNF are described, including typical failures encountered 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 into the SNF.
- Measures, Resources, and References: A recommended system of measures to guide improvement, worksheets and other tools to help teams implement the changes, and a bibliography of selected resources.
This guide was developed as part of the STate Action on Avoidable Rehospitalizations (STAAR) initiative.