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Service Delivery Innovation Profile

Transition Home Program Reduces Readmissions for Heart Failure Patients

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The Transition Home program at St. Luke's Hospital in Cedar Rapids, IA, incorporates a number of components to assure patients a safe transition to home or another health care setting. These components include an ongoing enhanced assessment of postdischarge needs, thorough patient and caregiver education, patient-centered communication with subsequent caregivers at handovers, and a standardized process for postacute care followup. The program reduced the 30-day all-cause readmission rate for patients from 12 to 10 percent (updated April 2014).

See Problem Addressed for new information about wider scope of program, Description for updates about expansion of the program to encompass all-cause readmissions, Results for updates on effects of the program on readmissions, and Planning and Development for source document (updated April 2014).

Evidence Rating (What is this?)

Moderate: The evidence consists of 30-day all cause readmission rate. In addition, Hospital Consumer Assessment of Healthcare Providers and Systems scores for questions 19 and 20 are displayed over time.
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Developing Organizations

St. Luke's Hospital
Cedar Rapids, IA
St. Luke's Hospital, part of UnityPoint Health (formerly the Iowa Health System), developed this innovation in conjunction with Transforming Care at the Bedside, a joint project of the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement.end do

Date First Implemented


Problem Addressed

Heart failure is associated with high rehospitalization rates, often due to preventable complications resulting from patients' inability to adequately self-manage the condition and poorly implemented transitions to the next care setting. Programs that provide adequate guidance at discharge, appropriate medication management, and appropriate followup with patients during times of transition can reduce readmission rates and improve quality of care.
  • Cycle of hospitalization: Almost one-third of heart failure patients are readmitted within 30 days of discharge.1 Although its 30-day heart failure readmission rate of 14 percent in March 2006 was below the national average, St. Luke's Hospital staff believed that this rate could be reduced even further.
  • Significant clinical and economic burden: Congestive heart failure (CHF) is the leading cause of hospitalization among older patients; furthermore, heart failure is associated with a substantial economic burden, with costs totaling $29.6 billion in 2006.1
  • Causes of rehospitalization: Causes of heart failure rehospitalization indicate a number of factors that could be addressed during the discharge process. These include, but are not limited to, deficiencies in patient self-care education, inappropriate medication reconciliation, poor communication among health care providers between sites of care, and lack of a plan for appropriate medical followup after discharge.2 Hospitalized patients are commonly subject to inadequate discharge processes that lead to clinical deterioration and increase the likelihood of rehospitalization; for example, one survey found that 81 percent of patients requiring assistance with basic functional needs failed to receive a home care referral at discharge, and 64 percent said that no one at the hospital talked to them about self-managing their care at home.3

What They Did

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Description of the Innovative Activity

The Transition Home program (designed as part of the Institute for Healthcare Improvement's Transforming Care at the Bedside [TCAB] program) emphasizes early and ongoing assessment of a patient's needs at discharge and incorporates enhanced education and caregiver communication processes. Key elements of the program include the following:
  • Enhanced ongoing admission assessment for postdischarge needs: On admission, the nurses in the medical surgical unit perform a discharge assessment to create an expected discharge plan. Planning for discharge includes the following:
    • Designating an accountable clinician: A caregiver whom the patient identifies as wanting to be involved in discharge care planning and education is identified.
    • Assessing discharge needs: Based on the typical course for the diagnosis as well as patient-specific needs, nurses predict the needs of the patient on discharge. Considerations include but are not limited to functional status, cognitive status, access to social and financial resources, home setting characteristics, medication and dietary restrictions, recommended activity level, assistive devices required, self-care required, and consideration for referral to home care or to a disease management program. Nurses request information from family caregivers and community providers (e.g., home health nurses, primary care physicians, clinic nurses) in determining patient needs. The units conduct a daily huddle with the charge nurse, unit case manager, and frontline nurse caring for the patient; goals of care and goals for discharge are discussed and the “patient story” is put together with all the input from those involved in the care (updated April 2014).
    • Reconciling medications: Medications are reconciled on admission. The hospital utilizes specific admission nurses to perform the medication reconciliation.
    • Working with other organizations: If the patient will be discharged to a home care agency, a nursing home, or a setting other than home, representatives of these agencies are contacted to inform them of the expected discharge date and to arrange for effective handoff.
    • Adjustment of initial plan: The care team, through the daily huddle and ongoing collaboration, reevaluate the discharge plan daily, adjust the plan of care, and adjust discharge preparations accordingly. Much of this communication is outlined on the patient's whiteboard in the room. Family members and caregivers really appreciate this information, which is readily available to them (updated April 2014).
    • Providing patient-friendly discharge instructions: Instructions include information such as where the patient is going, a list of remaining decisions that need to be made, information about safe and effective use of medications, followup care planned, self-care required, and contact information in case of emergency.
  • Thorough education for patients, caregivers: An enhanced teaching and learning process was implemented to ensure that patients and family members understand discharge instructions, self-care instructions, medications, and other postdischarge issues. Caregivers use the teach-back method in the hospital; home care providers repeat the education in the home, and the clinics use teach-back methods during followup appointments. Family caregivers are identified so that education can be provided to both the patient and the caregivers. Education techniques include the following:
    • Using basic communication strategies: Such strategies include speaking slowly; avoiding use of jargon; and using simple, short sentences. In addition, concepts of health literacy are incorporated into the teaching process both in written and verbal communication.
    • Asking patients and families how they learn best: Nurses provide alternatives such as enhanced education packets with written materials, videos and audiotapes, personalized discussions, and interpretive services.
    • "Ask Me 3": This technique, developed under the umbrella of the National Patient Safety Foundation, emphasizes three critical questions: (1) What is the main problem? (2) What should I do? and (3) Why is it important to do this? Professionals provide information that fits within these three questions.
    • Teach-back methodology: Patients are asked to repeat back educational information provided to confirm their understanding. Gaps in understanding are identified and retaught. St. Luke's has a competency validation for teach-back to ensure reliability of the teaching method in the nursing practice. Teach-back is part of the onboarding for new employees and in the nurse residency program. All medical and surgical nurses participate in an integrated care management course, which teaches and observes nurses in teachback, motivational interviewing, and patient engagement concepts (updated April 2014).
    • Return demonstrations: Patients are asked to demonstrate their ability to perform what was taught; for example, patients may be asked to weigh themselves and record their weight in front of the caregiver.
    • Small segments of critical material repeated frequently: Health topics are broken down into learnable sections (no more than four points at any given time); only essential information is provided (additional education can be provided after discharge). Patients are retaught this information each day to improve recall, with new content added if comprehension seems strong. Written material is provided to reinforce messages and to be used for home reference.
  • Patient-centered handover communication: A patient nurse or discharge nurse ensures that clinicians receiving the handover of the patient are provided complete information about the patient's functional and cognitive status, family resources, and care needs, including the medication regimen, self-care needs and abilities, and durable medical equipment needs. Other elements of effective handover include medication reconciliation, written information provided to the patient, and transmission of critical information to the next set of caregivers before discharge.
  • Postacute care followup: All patients are scheduled for a followup visit at 5 to 7 days postdischarge with a physician. This physician office visit is scheduled before discharge and addressed in the patient's discharge instructions. A hospital-based heart failure clinic facilitated by an advanced registered nurse practitioner was opened in August 2011. 

Context of the Innovation

St. Luke's Hospital in Cedar Rapids, part of UnityPoint Health (formerly the Iowa Health System), is a 500-bed hospital with more than 17,000 annual admissions. St. Luke's Hospital participated in the TCAB Project, a joint project of the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement, which focuses on improving the quality and safety of patient care on medical and surgical units, increasing the vitality and retention of nurses, improving the patient's/family's care experience, and improving the effectiveness of the care team. St. Luke's has had a large cross-continuum team since 2006; the team drives the work and collaborates on intervention.

Did It Work?

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The program has enabled St. Luke's Hospital to reduce its readmission rates; specific results include the following:
  • Reduction in readmission rates: Current 30-day all-cause readmission rates for St. Luke's hospital are the lowest they have been for 4 years at 10% (updated April 2014).
  • Post-hospital followup visits: Some 90 to 95 percent of followup visits that are scheduled before discharge are completed within 7 days of discharge (updated April 2014).
  • Rate of correct teach-back responses: Staff used patients' failed teach-back responses to improve teaching methods with regard to symptoms. As of December 2013, the rates at which the percentage of symptoms patients could teach back held steady: 80 percent in the hospital and approximately 85 percent in the home, with home care.
  • High patient satisfaction: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores for education are at 89 percent, higher than the national average of 84 percent (updated April 2014).

Evidence Rating (What is this?)

Moderate: The evidence consists of 30-day all cause readmission rate. In addition, Hospital Consumer Assessment of Healthcare Providers and Systems scores for questions 19 and 20 are displayed over time.

How They Did It

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Planning and Development Process

The Institute for Healthcare Improvement's How-to Guide: Improving Transitions From the Hospital to Community Settings to Reduce Avoidable Rehospitalizations outlines the planning and development process adopted by St. Luke's Hospital so that this process can be followed by other adopters. Key steps of this planning and development process are summarized below:
  • Form a team: Form a core team of five to seven people from various medical disciplines and roles (e.g., frontline nurses; nurse managers; pharmacists; discharge planners; rehabilitation therapists; clinic, long-term care, and home care representatives; office/practice staff members; and patient and family).
  • Identify opportunities for improvement: Review and analyze heart failure readmissions to identify failures in the current process. A line chart of the 30-day readmission rate of patients with heart failure was created to track past and future data.
  • Develop an aim statement: The aim statement should be time specific and measurable and should define the specific population of patients that would be affected.
  • Create a basic flowchart of the process: The flowchart should outline the major steps in the current discharge process and the care providers and disciplines involved. Then, flowcharts of subprocesses should be created.
  • Standardize each subprocess and measure its reliability: Standardize the steps in each subprocess and then measure whether and how often staff execute the process for a group of patients.
  • Redesign the process and test changes: Based on the findings from the previous step, redesign each subprocess with the goal of greater reliability. Changes can be refined through several Plan-Do-Study-Act cycles.
  • Measure progress: Establish key performance measures to identify whether changes constitute improvements.
  • Spread the new process: Spread the new process to other shifts or units.
  • Spread to other conditions: Information provided in April 2014 indicates that the original initiative is now being spread to all readmitted patients or high-risk patients.
  • Advance medical team pilot: Information provided in April 2014 indicates that the new process for heart failure is now the core for much of the work involved in any readmission and greater effort is put on care coordination across the continuum. Recently, an advance medical team was initiated for high-risk patients in specialty clinics; this team works closely with the hospital team. UnityPoint clinics are also implementing medical home in primary care clinics and care coordinators work with the team in creating ideal transitions. (Updated April 2014.)

Resources Used and Skills Needed

  • Staffing: No new staff members were hired by the program. Existing staff developed the new program and educational materials and absorbed enhanced teaching responsibilities and other duties into their daily activities. In the clinics, the advance medical team navigators and medical home care coordinator were positions. (Updated April 2014.)
  • Costs: Education materials average around $4,000 per year for each major diagnosis with which the team works (e.g., heart failure, myocardial infarction, pneumonia, open heart surgery, stroke, chronic obstructive pulmonary disease). Inhouse materials are used. (Updated April 2014.)
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Funding Sources

St. Luke's Hospital
St. Luke's Hospital was the funding source; the project received no direct funding from RWJF but did benefit from support from the Institute for Healthcare Improvement, specifically through faculty who led the program and consulted with St. Luke's during the innovation program.end fs

Tools and Other Resources

Nielsen GA, Bartely A, Coleman E, et al. Transforming care at the bedside how-to guide: creating an ideal transition home for patients with heart failure. A toolkit to help teams implement the innovation. Cambridge, MA: Institute for Healthcare Improvement; 2008. Available at:

Rutherford P, Nielsen GA, Taylor J, et al. How-to guide: improving transitions from the hospital to community settings to reduce avoidable rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at:

Adoption Considerations

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Getting Started with This Innovation

  • Share best practices: Expose teams at the adopting site to teams at other organizations who are also working on reducing heart failure readmissions. Colleagues at other sites can offer suggestions and solutions that can be very helpful.
  • Talk to patients and families: Survey patients and family caregivers to learn about failures in the discharge process and to get ideas for improvements. Track the questions patients ask during postdischarge phone calls to the hospital to gain insight on how discharge efforts might be improved.
  • Confirm who will be the family caregiver: Family visitors at the hospital may not be the people who will have the primary responsibility for caring for the patient after hospital discharge. Identify the patient's actual family caregivers during multidisciplinary rounds by asking who will be helping with care in the home.
  • Ensure excellence in patient education: Base education on well-established patient education tenets, standardize teaching materials, and use teach-back methods to ensure patient understanding. Develop teaching materials in multiple delivery methods, such as written materials, videotapes, and face-to-face discussions.
  • Ensure thorough medication reconciliation and communication: Medication reconciliation should be performed by a qualified clinician. At discharge, patients and families should be provided with a copy of the most recent medication list from the health record along with specific instructions for use of each medication.
  • Standardize appropriate patient followup care: Schedule the patient's post-hospital followup office visit before discharge. Standardize a system of followup phone calls to patients within 48 hours of discharge.
  • Work with clinicians in other settings to ensure optimal patient handoff: Talk with representatives of home care agencies, visiting nurse associations, and skilled nursing facilities to ask how they prefer to receive information and to ensure appropriate design of handoff communication tools, forms, and processes.

Sustaining This Innovation

  • Continue to implement process improvement: The program is being expanded to ensure process improvement in other diagnoses; program staff also continue to work with the cross-continuum team on improvement in skilled nursing facilities and office practices.
  • Even after the readmission rate goal is achieved, review every readmission to develop ideas for further improvement: Program developers at St. Luke's Hospital are sustaining program gains and continue to review all readmissions to determine how to continually improve the care process. The team is also now reviewing revisits to the emergency department within 30 days (i.e., the patient visited the emergency department and revisits within 30 days).
  • Incorporate teach-back as a nursing competency: Teach-back has become a competency validation for the St. Luke's nursing staff to ensure comfort with the process.

More Information

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Contact the Innovator

Peg Bradke, RN, MA
Vice President, Post-Acute Services
St. Luke's Hospital
1026 A Avenue NE, PO Box 3026
Cedar Rapids, IA 52406-3026
(319) 369-7269

Innovator Disclosures

Ms. Bradke reported having no financial interests or business or professional affiliations relevant to the work described in this profile.

References/Related Articles

Nielsen GA, Bartely A, Coleman E, et al. Transforming care at the bedside how-to guide: creating an ideal transition home for patients with heart failure. Cambridge, MA: Institute for Healthcare Improvement; 2008. Available at:

Rutherford P, Nielsen GA, Taylor J, et al. How-to guide: improving transitions from the hospital to community settings to reduce avoidable rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at:


1 Landro L. Keeping patients from landing back in hospital. Wall Street Journal. December 12, 2007. Available at:
2 Nielsen GA, Bartely A, Coleman E, et al. Transforming care at the bedside how-to guide: creating an ideal transition home for patients with heart failure. Cambridge, MA: Institute for Healthcare Improvement; 2008. Available at:
3 Clark PA. Patient satisfaction and the discharge process: evidence-based best practices. Marblehead, MA: HcPro, Inc.; 2006.
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: February 16, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: September 10, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: April 02, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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