Patients can experience significant challenges as they transition from the hospital to their homes or other care settings in their community. They may have difficulty understanding their discharge instructions, receive conflicting information from various health care providers or experience serious medication errors, all of which can cause complications and land them back in the hospital unnecessarily.

Through our Betty Irene Moore Nursing Initiative, we sought to change this situation. We worked with 26 hospitals throughout the San Francisco Bay Area to improve coordination of care with the goal of reducing the number of preventable hospital readmissions. Efforts focused on implementing community-based transitional care models with a proven record of success. Examples of various approaches included:

  • Identifying the root causes of readmissions and the patients at highest risk.
  • Using the teach-back method for patient education to ensure patients understand their discharge instructions.
  • Carrying out follow-up phone calls and home visits with discharged patients.
  • Scheduling a follow-up appointment for patients before they leave the hospital.
  • Conducting medication reconciliation to ensure patients’ medication lists are accurate.

These practices, along with other interventions, resulted in 30 percent of San Francisco Bay Area hospitals reducing 30-day readmission rates by 30 percent and/or 90-day readmission rates by 15 percent. We invite you to learn more about our partners’ approaches to transitional care by watching this brief video.

To continue sharing approaches and successful models with the field, we created Huddle for Care, a first-of-its kind online community to connect care coordinators from across the country. Huddle for Care gives its users the opportunity to learn from others working to improve care transitions by sharing model programs, success stories and advice on how to safely and efficiently transition their patients from the hospital back to their homes or other care settings. Read more about Huddle for Care here.



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