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Home to Stay Collaborative

Spreading the learning

The Collaborative finished in March 2017. Selected resources are still available for use.

We are taking the lessons learned from this project and spreading them to our work to reduce rehospitalizations across Idaho and Washington.

Home to Stay was a regional Collaborative to support skilled nursing facilities in implementing a standardized discharge process, with the overall goals of:

  • Ensuring short-stay residents remain safely at home after being released from a SNF
     
  • Reducing 30-day rehospitalizations
     
  • Improving short-stay residents’ satisfaction

During this Collaborative, participants used Plan-Do-Study-Act (PDSA) cycles and real-time data to systematically implement a standardized discharge process and related best practices. It was also designed to incorporate feedback from short-stay residents and their families—resident-centeredness in action!

rehospitalization graph