Transitional Care: 90‑Day Implementation Journey

Practical, team-centered guidance to pilot and scale transitional care bundles and community partnerships that reduce post-discharge harm and improve continuity of care.

Why this matters

Most harm after hospital discharge comes from predictable gaps: unclear responsibilities, un-reconciled medications, missed follow-up, and unaddressed social needs. A focused 90‑day implementation journey helps teams move from ideas to repeatable practice by defining a measurable pilot, clarifying roles, and connecting with receiving providers and community partners.

What you will understand and accomplish

By following this journey teams will:

• Design a contextualized transitional care bundle (discharge checklist, medication reconciliation, follow‑up plan, patient education and community linkages).
• Create a 90‑day pilot plan with clear owners, measures, and simple data collection to test impact and operational feasibility.
• Practice structured handoffs that include risk stratification and receiving‑provider constraints (home health, primary care, skilled nursing, community resources).
• Use short measurement cycles to learn, iterate, and prepare for scale or wider adoption.

Who benefits

This resource is designed for multidisciplinary improvement teams: hospital discharge planners, care managers, nurses, pharmacists, primary care and specialty clinics, home‑health and community partners, quality improvement staff, and operational leaders in hospitals, clinics, and post‑acute networks. It works for small teams piloting a process at one unit and for system teams preparing an accountable rollout.

Practical examples

Examples of pilots you can run in 90 days:

• CHF discharge bundle: pharmacist‑led med reconciliation, scheduled primary‑care follow‑up within 7 days, home‑health referral for high‑risk patients.
• Post‑surgical same‑day discharge: nurse navigator phone check at 48–72 hours, reinforced wound‑care instructions, and a community clinic booking workflow.
• Behavioral health transition: warm handoff to outpatient therapy, transportation support via community partners, and follow‑up appointment confirmation before discharge.

How this resource fits into the Care Coordination & Transitions domain

This 90‑day journey complements standard work on discharge planning and care coordination by emphasizing measurable pilots and community engagement. It helps teams operationalize the parent domain’s goals—clear discharge plans, medication reconciliation, timely follow‑up—while preventing common failures such as fragmented handoffs or one‑size‑fits‑all processes.

Platform affordances that make the journey practical

The included journey module is designed to be copied and tailored to your site: you can adapt the 90‑day pilot plan template to local roles and constraints, capture pilot measurements with simple interactive forms, and save structured responses for later review and handoff audits. Use short PDSA cycles and the template’s measurement fields to keep learning visible and actionable.