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Transitioning to Home Health Care

Transitions in care are an opportunity to improve the quality, safety, and cost-efficiency of patient care pathways. The transition into home health care can be meaningfully and measurably improved for patients, their families, inpatient, outpatient, and home health care providers through establishing clearly defined "shared expectations" between referring providers and accepting home health agencies.

These “shared expectations" create a voluntary, standardized set of administrative and clinical practices that referring providers and accepting agencies – regardless of system or local referral market – can collectively recognize as independent and interdependent processes that can help define high-performance and reflect evolving models of integrated and accountable care.

The following resources focus on the transition from hospital to home, or from a skilled nursing facility (SNF) to home health care. They outline performance expectations of hospital/ SNFs ("senders") and home health agencies ("receivers") as they accept a patient from the acute/post-acute facility setting and initiate home health care. In addition, they outline practices home health agencies will take as "senders," if a change in care setting is required.

Shared Expectations Resources

Other Resources