IHI recommends these 4 elements at the time of hospital discharge:
- Enhanced assessment of post-discharge needs;
- Enhanced teaching/learning;
- Enhanced communication at discharge; and
- Timely post-acute follow up
IHI states that success is dependent on active partnerships with providers across the continuum of care: hospitals, skilled nursing facilities, home health, ambulatory settings and patient/caregiver.
The focus of this project will have implications in healthcare payment reform, so it will be important to follow the progress of this project. There's a strong emphasis on improving care transitions and to identify those important services that will enhance this process. Unfortunately, many of these services are currently not reimbursed. It will require an out-of-the-box thinking beyond the current fee-for-service payment model in order to finally develop solutions that really work.