Institute for Healthcare Improvement
Cambridge, Massachusetts, USA
How to cite this document:
Sevin C, Evdokimoff M, Sobolewski S, Taylor J, Rutherford P, Coleman EA. How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at www.IHI.org.
This How-to Guide is designed to support home health care improvement teams and their hospital and community partners in codesigning and reliably implementing improved care processes to ensure that patients who have been discharged from the hospital have an effective transition into home health care in the first 48 hours after discharge from the hospital, a post-acute care setting, or a rehabilitation facility.
The Guide includes:
- Key Changes: Three key recommendations for improving the transition out of the hospital 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.
- 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.