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Betty Irene Moore Nursing Initiative

Transitional Care

Patients can experience significant challenges as they transition from the hospital to their homes or other care settings. 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 preventable readmissions to the hospital. According to a study published in the New England Journal of Medicine, twenty percent of Medicare patients are readmitted to the hospital within 30 days of discharge.

We believe that providing high-quality care before, during and after patients transition from the hospital is key to helping them stay healthy. Our transitional care strategy seeks to provide such care locally. Our goal is to support San Francisco Bay Area hospitals and their partner organizations to improve transitional care in order to reduce preventable readmission rates and enhance overall care. We have worked with 75 percent of local hospitals to implement evidence-based transitional care models. As part of these models, our partner hospitals have instituted key interventions such as:

  • 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.

As a result of these and other interventions, to date, we have seen 30 percent of San Francisco Bay Area hospitals reduce 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 the brief video below. Highlighting unique stories, lessons learned and effective interventions and tools, this video brings to life how successful implementation approaches can improve transitional care, reduce preventable readmissions and help improve the lives of patients.

By sharing our partners’ success stories, we hope to stimulate national interest in transitional care and to inspire collaboration among hospitals and other care settings. Ultimately, it is our hope that all hospitals and care settings have the right tools, strategies and information needed to reduce unnecessary hospital readmissions. For more information about our transitional care strategy and partners, we encourage you to contact us at