This guide, provided by the Institute for Healthcare Improvement, is designed to support hospital-based teams and their community partners in code signing and reliably implementing improved care processed to ensure that patients who have been discharged from the hospital have an ideal transition to the next setting of care.

This how-to guide is designed to support hospital-based teams and their community partners in creating an ideal reception in home health in the first 48 hours after the patient is discharged from the hospital, a post-acute care setting or a rehabilitation facility.

Patients are more at risk for experiencing gaps in care that lead to rehospitalization during the transition between care settings. The focus of this guide is the transition of residents from hospital to the skilled nursing facility (SNF) setting and the associated transfer of responsibility from the hospital to the SNF care team.

This guide focuses on the reception of patients back into the office practice after hospitalization. Patients are especially vulnerable to adverse events in the period immediately following discharge, and they need immediate access to a trusted clinician who can answer questions, provide advice, and help ensure that their clinical conditions remains stable.

View more information about the Bridge Model and linking hospital-based services with the aging network.

People can prevent or delay type 2 diabetes when they join the Centers for Disease Control and Prevention's (CDC’s) National Diabetes Prevention Program lifestyle change program. While lowering risk for type 2 diabetes, people can also improve their health and build healthy habits that last a lifetime.

The Agency for Healthcare Research and Quality, in coordination with Boston University Medical Center, has developed an online Re-Engineered Discharge (RED) tool kit. RED has been shown to be effective in reducing readmissions and post-hospital emergency department visits.