90‑Day Transitional Care Pilot Plan Template

Welcome

This 90‑day pilot plan helps care teams design, test, measure, and spread a transitional care bundle that reduces harm after discharge for high‑risk patients. It focuses on a clear, measurable pilot with defined roles, partner engagement, simple data collection, and a concrete spread plan so successful pilots can endure beyond one-off trials.

What this module provides

• A four‑phase 90‑day timeline with concrete activities and deliverables
• Baseline audit checklist to understand current performance
• Detailed bundle components (medication reconciliation, home visit, follow-up, care plan transfer, teach‑back)
• Stakeholder engagement map template
• Pilot evaluation metrics (process, outcome, balancing) with sample KPI definitions
• A simple spread and sustainment plan

How to use this plan

Assemble a small cross‑functional pilot team (clinical lead, nurse coordinator/case manager, pharmacist, data/analytics contact, social work/community partner liaison, improvement coach). Use rapid weekly check‑ins, collect compact data that answer whether the bundle is being delivered and moving outcomes, and iterate quickly on the bundle components.

90‑Day phased roadmap

Phase: Prepare (Days 0–14)

• Clarify pilot aim (example: reduce 30‑day readmissions among high‑risk CHF patients by 20% in pilot cohort vs baseline)
• Define inclusion/exclusion criteria and target population (risk stratification method)
• Map current discharge process and run a baseline audit (use checklist below)
• Identify community partners (home health, primary care clinics, social services) and secure commitments
• Agree data collection approach, sources, and responsible persons

Phase: Launch (Days 15–30)

• Train pilot staff on bundle components and documentation expectations
• Start enrolling patients and begin delivering the bundle
• Collect process measures daily/weekly (e.g., % of discharges with med reconciliation complete)
• Hold weekly huddles to remove barriers

Phase: Iterate & Monitor (Days 31–60)

• Use run charts or simple dashboard to track process and outcome measures
• Apply small plan‑do‑study‑act cycles to fix bottlenecks
• Collect qualitative feedback from patients and partners

Phase: Evaluate & Spread (Days 61–90)

• Run a formal pilot evaluation against pre‑specified metrics
• Decide go/no‑go and define criteria for spreading
• Document standard work, training materials, and a 30‑60‑90 day rollout plan for next sites
• Plan sustainment (data ownership, regular measurement cadence, governance)

Baseline audit checklist (sample items)

Use this quick audit to establish baseline rates and identify gaps.

• Risk stratification performed and recorded at admission/discharge?
• Medication reconciliation completed and reconciled with outpatient meds documented?
• Follow‑up appointment scheduled with primary care or specialty within 7 days of discharge?
• Patient received teach‑back on key meds and warning signs?
• Discharge summary transmitted to PCP within 48 hours?
• Home visit or community nursing referral made for high‑risk patients?
• Social needs screening completed and referrals made when indicated?

Bundle components – practical details

1. Medication reconciliation

• Compare inpatient medication list to pre‑admission meds and patient's current list.
• Resolve discrepancies with prescriber and document changes in discharge summary.
• Provide printed medication list and simple dosing schedule to patient/caregiver.

2. Home visit or early outpatient contact

• Target within 48–72 hours for highest‑risk patients; identify who performs the visit (home health, community nurse, outreach team).
• Checklist for visit: meds on hand, symptom assessment, durable medical equipment, home safety, contact plan.

3. Follow‑up call within 48–72 hours

• Use a short script: confirm meds, appointments, symptom worsening, ability to obtain meds and meals, clarity on red flags and who to call.
• Escalation protocol if concerns identified.

4. Teach‑back & patient education

• Use teach‑back for at least one high‑priority instruction (meds or symptom action plan).
• Provide clear written materials and list of contacts for questions.

5. Care plan transfer

• Ensure discharge summary and problem list are transmitted to PCP and other relevant clinicians within 48 hours.

Stakeholder engagement map (template)

Identify stakeholders, their role, and the specific ask.

• Internal: Hospitalist/Clinical lead – clinical oversight; Data analyst – measures & dashboard; Pharmacy – med reconciliation protocol; Nursing – discharge workflow; Case management – scheduling & referrals.
• Community partners: Home health – home visits; Primary care clinics – timely appointments; Social services – SDOH referrals.
• Executive sponsor: help unblock resources and support spread.

Pilot evaluation metrics (recommended)

Define measures up front. Collect enough data to show a signal but keep it simple.

• Process measures (how often the bundle is delivered): % of enrolled discharges with complete med reconciliation; % with 48–72 hour follow‑up call completed; % with home visit scheduled/complete.
  • Frequency: weekly
  • Data source: EHR checklist, pilot form
• Outcome measures (patient impact): 30‑day all‑cause readmission rate in pilot cohort; ED visits within 30 days.
  • Frequency: monthly
  • Data source: admission records, EHR queries
• Balancing measures: staff time per discharge; % of patients reporting confusion about meds; unplanned workload on community partners.
  • Frequency: weekly or biweekly

Data collection & documentation (practical options)

Begin with the simplest reliable method: a short EHR smartform or a shared pilot spreadsheet. Use a minimal set of fields: patient ID, enrollment date, risk score, which bundle elements delivered (checkboxes), date of follow‑up call, home visit completed (Y/N), readmission within 30 days (Y/N), comments.

When the platform capabilities are available, convert the baseline audit and daily/weekly pilot tracker into interactive forms that save JSON submissions so the team can run simple dashboards and export results for analytics.

Spread plan & sustainment

• Define explicit success criteria (e.g., >80% delivery of key bundle components and a measurable reduction in readmission signal consistent over 2 consecutive months).
• Document standard work, training checklist, and a short playbook for onboarding new units or sites.
• Assign data owner and governance cadence (who produces the weekly run chart, who reviews it monthly, who decides to scale).
• Plan partner MOUs or agreements for community services to ensure capacity when scaling.

Common pitfalls and tips

• Pitfall: trying to measure too many things. Tip: start with 3–5 key measures and add only if needed.
• Pitfall: unclear roles for bundle tasks. Tip: map tasks to job titles and include the assignments in the discharge checklist.
• Pitfall: lack of partner capacity. Tip: formalize expectations early and test small volumes first.

Next steps

1. Customize inclusion criteria and aims for your population.
2. Run the baseline audit on a convenience sample of recent discharges.
3. Stand up the pilot data collection form and begin a two‑week trial.
4. Use weekly huddles to iterate and prepare the formal evaluation at day 60–90.

When you’re ready, convert the baseline audit and pilot tracker into interactive forms so the team can submit and store pilot data, run simple dashboards, and preserve organizational learning for future spread.