Written by: Center for Care Innovations

Idea: ​Improve care coordination during patients’ transitions from the hospital to primary care.

Target: Pre-discharge hospital inpatients with congestive heart failure, chronic obstructive pulmonary disease or diabetes, plus two or more hospital or emergency visits in the previous 12 months.

Project Highlights: Based on anecdotal practice knowledge, SJGH predicted that 9 of 10 readmissions that take place within one week of discharge—when many readmissions happen—could be prevented with an organized transitional care program. Before thinking about possible solutions, team members immersed themselves in the problem and talked to patients to better understand their needs and insights. The Innovation Team identified a number of “transition points” that contribute to the fact that “transitional care between the hospital and the PCP is a critical broken component in the current system,” especially for low income and uninsured patients.

Evidence of Cultural Change from the Innovation Process:

• Developed a stronger, focused team after going through the innovation process –and a team with the same vision. Their strategy included identifying key people and creating a team with a core, but one that was flexible enough to absorb other talent.

• Initially, providers could not think beyond their own “borders” in the health care system. The project facilitated a shift in how providers in their own setting began to understand patient needs before, during, after hospital discharge.


Negative Home Visit Form

Phone Follow-Up Form

Post-Discharge Follow-Up Report Form: Congestive Heart Failure

Post-Discharge Follow-Up Report Form: Chronic Obstructive Pulmonary Disease

Post-Discharge Follow-Up Report Form: Diabetes

Discharge Stoplight Tools