Rural settings have multiple layers of health care and social support services to draw on for patient care and coordination. Using the hospital/swing bed program as the organizer, this is an opportunity to initiate or enhance one of two projects: building/maintaining a community-wide working committee to address patient needs following health care issues; OR initiate or enhance an aging in place project. Both projects are designed to help patients after discharge from acute or swing bed to help them maintain their health and independence with the provision of community services – hospital to transportation, coordination between hospital services and other health providers, assistance with life and social needs being addressed. The patient is assisted into the right setting at the right time with the right support needed. Check out two courses that focus on the 'making it real' and 'making it better' considerations and impacts for successful transitions of care for patients!

Implementation: Transitions of Care: Making it Real

Upon completion of this presentation, you should be able to:

• Define use of data for projects
• Identify other sources of data
• Recall community coalition basics
• Describe aging in place projects
• Discuss ways to initiate or enhance community projects
• Recall next steps for success

Improvement: Transitions of Care: Making it Better

Upon completion of this presentation, you should be able to:

• Define the strengths of the discharge planning process
• Describe gaps in discharge planning choices
• Identify services support for discharged patients
• Identify hospital discharge data for planning
• Explain how to Initiate a community coalition program
• Recall next steps to “make it better"