How-to Guide: Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations


Key Questions: How can transitions from the hospital to the clinical office practice be improved? Can this improvement reduce avoidable rehospitalizations? 

This guide is designed to be a conceptual framework or roadmap that depicts the interventions and elements of care needed to dramatically improve care of patients after they are discharged from the hospital. 

The purpose of this instructional guide is to provide information for practice-based clinicians and staff to co-design and reliably implement improved care processes to ensure that patients who have been discharged from the hospital have an ideal transition back to the care team in the office practice.



  • 4 recommended key changes to improve the transition for the patient from the hospital to the clinical office practice setting, including typical failures encountered and tools and resources to help teams implement the changes.
  • Infrastructure and Strategy to Achieve Results: A review of the necessary leadership support and fundamental improvement methods and resources for testing changes before they are implemented and spread more widely throughout the organization.
  • Case Studies: The cases provide examples of how organizations implemented the key changes to improve transitions from the hospital to the office practice.
  • Measures, Resources, and References: A recommended system of measures to guide improvement, worksheets and other tools to help teams implement the changes, and a bibliography of selected resources.
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Institute for Healthcare Improvement

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Improving Care Transitions, Reducing Avoidable Hospital Readmissions

Reducing mortality and readmissions rates