The Home to Stay Collaborative ended in March 2017. A key tool used during the Collaborative was the Discharge Preparation Checklist. The participant handbook, CTM-3 survey forms, and a recording of the Outcomes Congress are also available.
We are taking the lessons learned from this project and spreading them to our work to reduce rehospitalizations across Idaho and Washington.
Download the checklist to use as-is, or incorporate the steps into your existing workflow. (Video: how one nursing home describe their use of the checklist.) We also developed an Excel workbook to track post-discharge details.
The following resources provide more detail about some of the concepts covered in the checklist.
See our one-page summary Tips for Obtaining Best Possible Medication History, and the more detailed resources we have assembled related to medication reconciliation.
Use the Teach Back method to ensure the resident understands all medication-related instructions.
Your facility may decide to provide soon-to-be-discharged residents with a personalized medication list; several organizations have created useful templates for this purpose.
Teach Back is an easy-to-learn, reliable method to ensure the resident and family understand each element.
To get more feedback, consider using the CTM-3 to survey residents and their family about how their discharge experience.
You may want to supplement your discharge teaching with a video. (Nursing homes are welcome to modify or use our version, which was developed for hospital discharges).
5. Educate about diagnosis.
6. Teach a written discharge plan.
7. Assess the degree of understanding.
8. Review what to do if a problem arises.
Describe the "red flags" (symptoms requiring a call or visit with the doctor) so that a worsening condition can be addressed before rehospitalization is needed.
9. Expedite transmission of the discharge summary to clinicians accepting care of the resident.
Does your facility systematically communicate information about the patient's immunization status and/or existing infections?
10. Provide telephone reinforcement of the discharge plan.
Handbook
Download a copy of the HTSC Handbook
Conducting Plan-Do-Study-Act (PDSA) cycles
Get a basic introduction to PDSAs
Care Transitions Measure (CTM-3) Survey
As part of the Home to Stay Collaborative, teams reported survey attempts, response rates, and results to Qualis Health. These tools were tailored for the HTSC and used with permission from Eric A. Coleman, MD MPH.