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Betty Irene Moore Nursing Initiative

Transitional Care

The Nursing Initiative’s transitional care strategy aims to improve patient care during the hospital discharge process and in the first few weeks thereafter—so that patients aren’t returning to the hospital as frequently. According to the New England Journal of Medicine one in five discharged Medicare patients (about two million people annually) return to the hospital within 30 days. Improving the transition after a hospitalization is key to ensuring the best outcomes for the patient. And nurses play a significant role in providing support, information and a seamless handoff to the next provider as patients leave the hospital. 

Our goal is to improve patients’ transitions from the hospital to the next care setting by helping San Francisco Bay Area hospitals implement innovative care models proven to reduce unnecessary readmissions. Our target is to reduce 30-day and 90-day hospital readmissions and measure the improvement in patient safety resulting from the implementation of these care models. 

The programs supported by this strategy are guided by the following tenets:

  • Understanding root causes to determine the reasons for safety issues during hospital discharges and unnecessary readmissions
  • Staying focused on improvement by using hospitals’ own data about unnecessary readmissions to improve their care during transitions
  • Following patient-focused, evidence-based care models so that hospitals learn how to implement practices shown to improve transitions, such helping patients understand how to manage medications after discharge
  • Improving communication and forming strong alignments with hospital and health system priorities to ensure that changes are sustained

We encourage collaboration among hospitals working to improve care transitions for their patients, and we seek to accelerate change by sharing bright spots as well as lessons from failures. Hospitals are encouraged to team with community partners such as home health providers, senior centers and outpatient doctors to ensure that patients and caregivers have the resources and support they need after leaving the hospital.

As San Francisco Bay Area hospitals successfully improve patient experience and reduce hospital readmissions, lessons can be shared with hospitals in California and across the nation through publications, webinars, tool kits and technical assistance.