IHI Collaborative: Hospital to home, Optimizing the Transition

Geriatric Resources for Assessment and Care of Elders (GRACE): A New Model of Primary Care for Low-Income Seniors. J Am Geriatr Soc. 2006;54(7):1136-1141.
August 7, 2019
St. Luke’s Hospital: Where Patients’ Home Care Needs Are Anticipated at Discharge
August 7, 2019

IHI Collaborative: Hospital to home, Optimizing the Transition

IHI has found that a comprehensive and reliable discharge plan, along with post discharge support, can reduce readmission rates, improve health outcomes and assure quality transitions. The goal of this Web&ACTION is to work with teams to optimize communications, support and involve patients and families, and eliminate waste and improve workflow using ideas that have been tested on the discharges of patients with heart failure (HF) on medical-surgical units. Upon completion of this Web&ACTION, participants will be able to: • Reduce unplanned admissions for patients with heart failure • Understand and collect key data regarding hospital readmissions • Describe and test top ideas for reducing heart failure readmissions to hospitals • Increase patient involvement in their care while in the hospital and after discharge

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