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How-to Guide: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations

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.

Background

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

Documents

How-to Guide: Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations

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How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations
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, with the related goal of reducing avoidable readmissions.
How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations
This How-to Guide is designed to support home health care improvement teams and their hospital and 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, with the related goal of reducing avoidable rehospitalizations.
How-to Guide: Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations
This How-to Guide is designed to support office practice-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 back to the care team in the office practice, with the related goal of reducing avoidable readmissions.

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How-to Guide: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations

Documents