Transforming Care at the Bedside How-to Guide: Creating an Ideal Transition Home for Patients with Heart Failure

Institute for Healthcare Improvement (in collaboration with the Robert Wood Johnson Foundation)
Cambridge, Massachusetts, USA

Last updated: June 2008

How to cite this document:
Nielsen GA, Bartely A, Coleman E, Resar R, Rutherford P, Souw D, Taylor J. Transforming Care at the Bedside How-to Guide: Creating an Ideal Transition Home for Patients with Heart Failure. Cambridge, MA: Institute for Healthcare Improvement; 2008. Available at
Launched in 2003, Transforming Care at the Bedside (TCAB) is a national program of the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement (IHI).
One of the most promising changes that has been developed within TCAB is “creating an ideal transition home” for patients who are being discharged from medical and surgical units within hospitals. This How-to Guide builds upon relevant research and published literature, and integrates what TCAB hospitals have learned as they strive to dramatically improve the quality of care for patients discharged from the hospital to home or to another health care facility.
Although this guide specifically focuses on patients with heart failure (HF), the proposed changes for creating an ideal transition home can be generalized and adapted to improve the discharge process for all patients.
The How-to Guide is divided into three sections:
  • Section One highlights four key components of an ideal transition home and specifies individual changes that can be tested. Key references and links to resources are included.
  • Section Two outlines a practical step-by-step sequence of activities to assist staff in testing and adapting many of the proposed changes described in Section One.
  • Section Three includes tools, resources, practical ”real-world” tips, examples from hospitals, and case studies of hospitals that have implemented many of the changes proposed in this guide.

The Transitions Home How-to Guide is designed to build on the initial work of IHI's 5 Million Lives Campaign intervention to deliver reliable, evidence-based care for congestive heart failure (CHF) in order to avoid readmissions and achieve improved outcomes for patients with heart failure.

Please note: Clinical content evolves rapidly as the scientific evidence-base changes. The content of this report was last updated June 2008.

Therefore, this report may not reflect scientific changes that have taken place since that time and may not be aligned with the most recent clinical evidence and practice guidelines. The information provided in this report is for informational purposes only, and is not diagnostic or formal clinical guidance. IHI expressly disclaims any and all representations and warranties with respect to the content of the report, including without limitation any representation or warranty with respect to the accuracy of such information or its fitness for a particular purpose. Further, IHI expressly disclaims any obligation to update this report. By downloading this report, you agree, for yourself and on behalf of your organization, if any, that IHI expressly disclaims and shall have no exposure for any and all liabilities, losses, or damages of any type or nature, regardless of the theory pursuant to which the claim for such liabilities, losses, or damages are brought, and whether such liabilities, losses, or damages are direct, indirect, incidental, special, punitive, or consequential.

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