How-to Guide: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations


Key Questions: How can transitions from the hospital to skilled nursing facilities 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.

This How-to Guide was developed as part of the STate Action on Avoidable Rehospitalizations (STAAR) initiative to support teams in skilled nursing facilities (SNFs) and their community partners in co-designing and reliably implementing improved care processes to ensure that residents have a safe, effective transition into — and are actively received by — the SNF.



  • Introduction
  • Key Changes
  • Design Elements
  • Infrastructure and Strategy to Achieve Results
  • System of Measures
  • Case Study
  • How-to Guide Resources
  • References
Contact Person/Organization: 

Institute for Healthcare Improvement

Type of Tool:

Publication Date: 

INTERACT Program Overview

Reducing Avoidable Readmissions Effectively (RARE) Webinar