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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 
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 
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