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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.

Discharge Preparation Checklist

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.

Plan

Schedule follow-up medical appointments and post-discharge tests / labs.
Plan for the follow-up of tests that are pending at discharge.
Arrange for post-discharge outpatient services and medical equipment.
Identify the correct medications and a plan for the resident to obtain and take them.

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).

Teach Resident & Family

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.

Follow Up

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.

Recorded March 1, 2017

View the slides (pdf)
Review the recording (wmv)

In the final event of the Home to Stay Collaborative, we celebrated participants' successes and discussed lessons that teams learned along the way.

Peer Sharing

Hear from nursing homes and home health agencies that developed more effective processes to better serve their shared patients.

Recognition

We honored the contributions of many participants—for outstanding attendance, consistent reporting, much-appreciated webinar presentations, and more!

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.