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

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 2013. 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:
  • Key Changes: Four 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.
  • Case Studies: The cases provide examples of how organizations implemented the key changes to improve transitions from the hospital. 
  • Measures, Resources, and References: A recommended system of measures to guide improvement, worksheets and other tools to help hospital teams implement the changes, and a bibliography of selected resources.
Background
This guide was developed as part of the STate Action on Avoidable Rehospitalizations (STAAR) initiative.
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