TABLE 1

Strategies Identified by Participants To Improve Transitional Care, by Domain

Strategies
Home health orders
 Physicians writing accurate and specific orders for home care
 Physicians writing orders for home supplies well in advance of discharge
Communication
 Hospital sending discharge summaries to agencies
 Clinicians communicating with home health providers about CMC’s medical and social situations
Resources
 Nurses providing child-specific clinical training (“orienting”) to home health providers
 Identifying hospital-based clinician(s) to serve as a resource(s) for home health providers
 Physicians communicating with CMC’s PCP
Caregiver preparation
 Preparing caregivers about clinical care of CMC
 Preparing caregivers about home health nursing services
 Preparing caregivers about differences between hospital and home care