How-to Guide: Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations

Institute for Healthcare Improvement
Cambridge, Massachusetts, USA

How to cite this document:

Schall M, Coleman E, Rutherford P, Taylor J. How-to Guide: Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at

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. Patients are especially vulnerable to adverse events in the period immediately following discharge, and they need immediate access to a trusted clinician who can answer questions, provide advice, and help ensure that their clinical condition remains stable.

The approaches presented in this How-to Guide are intended to be a resource for clinicians and staff in office practices as they create new ways to provide optimal care for their patients.

The Guide includes:

  • Key Changes: Four recommended changes for improving the transition for the patient from the hospital to the clinical office practice setting, 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 to the office practice.
  • 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.

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