The challenge of improving transitional care: lessons learned in a home healthcare agency.

This article describes the efforts undertaken to reduce avoidable hospitalizations in a large, not-for-profit home healthcare agency over a period of 4 years by focusing on the improvement of transitional care-that is, moving patients from 1 level of care to another. Beginning as an effort to simply "teach" home care staff about best-practice tools, the challenges of implementing the changes required to improve the transition period were found to be complex and associated with a number of factors, ranging from the variation in discharge processes across hospitals to how clinicians perceived their roles and those of patients in the transition process. The author discusses the insights gleaned from the work that has been completed-and the work that still remains-while steadily decreasing the home healthcare agency's overall hospitalization rate.