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Improving Care Transitions From Hospital to Home: Standardized Orders for Home Health Nursing With Remote Telemonitoring

Heeke, Sheila DNP, RN, FNP-BC; Wood, Felecia DSN, RN, CNL; Schuck, Jennifer MBA, LMSW

doi: 10.1097/NCQ.0b013e3182a520b6

A task force at a multihospital health care system partnered with home health agencies to improve gaps during the discharge transition process. A standardized order template for home health nursing and remote telemonitoring was developed to decrease discrepancies in communication between hospital health care providers and home health nurses caring for patients with heart failure. Pilot results showed significantly improved communication with no readmissions, using the order template.

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Cardiology (Dr Heeke) and Care Coordination (Ms Schuck), Emory Healthcare, Inc, Atlanta, Georgia; Capstone College of Nursing, University of Alabama, Tuscaloosa (Dr Wood); and Wesley Woods Geriatric Hospital, Atlanta, Georgia (Ms Schuck). Dr Heeke is now with Neurological Surgery, Emory Healthcare, Inc, Atlanta, Georgia.

Correspondence: Sheila Heeke, DNP, RN, FNP-BC, Neurological Surgery, Emory Healthcare, Inc, 1364 Clifton Rd, B2200, Atlanta, GA 30032 (

The authors declare no conflict of interest.

Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (

Accepted for publication: July 15, 2013

Published ahead of print: August 9, 2013

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins