Rutherford, P., Nielsen, G.A., Taylor, J., Bradke, P., & Coleman, E. (2011). How-to Guide: Improving Transitions from the Hospital to Post-Acute Care Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement. Retrieved from http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideImprovingTransitionstoReduceAvoidableRehospitalizations.aspx.
“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:
- Getting Started: This section lists steps to get started on creating an ideal transition for patients being discharged from the hospital, a post-acute care setting, or a rehabilitation facility.
- Key Changes: Four key recommendations for improving the transition out of the hospital are described, including typical failures encountered, recommended measures to guide improvement, and tools and resources to help teams implement the changes.
- Testing, Implementing, and Spreading Changes: A review of 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.
- Resources and References: Worksheets and other tools to help hospital teams implement the changes, along with a bibliography of selected resources.”