title: An evidence-based strategy for transitioning patients from the hospital to the community.
abstract: Improving transitional care from hospital to home requires comprehensive and highly coordinated intervention during the immediate days following discharge. The Hospital to Home Program addresses both medical and social needs, prevents unnecessary readmissions, promotes improvements in patient perceptions of physical and mental health, and results in excellent patient satisfaction.
authors.affiliation: Post Acute Services, Forsyth Medical Center, Winston-Salem, NC 27103, USA. Iwwatkins@novanthealth.org
authors.forename: Lynn
authors.initials: L
authors.lastname: Watkins
mesh_terms: D000203:Activities of Daily Living; D000368:Aged; D002908:Chronic Disease; D015897:Comorbidity; D003266:Continuity of Patient Care / Q000458:organization & administration* / Q000592:standards; D055317:Evidence-Based Practice; D018575:Home Care Services, Hospital-Based / Q000458:organization & administration* / Q000592:standards; D006801:Humans; D009657:North Carolina; D010351:Patient Discharge / Q000592:standards*; D010359:Patient Readmission / Q000592:standards*; D019984:Quality Indicators, Health Care / Q000592:standards; D018570:Risk Assessment / Q000379:methods; D012944:Social Support