Building a seamless system of hospital-home health services.

Robert Wood Johnson University Hospital is committed to expanding the continuum of care. To this end, 2 task forces were developed simultaneously. One was created to streamline the discharge transition planning process and produce a more efficient and effective system. The other focused specifically on the coronary artery bypass graft population, with the objective of reducing length of stay without compromising quality of care. This article describes the process from the perspective of the Home Care Department's involvement. Computerization, standardization of physician orders and nursing care plans, and testing patients' knowledge regarding nutrition and medications after discharge from the hospital are described in detail. Including home care in the planning process is the key to achieving a seamless continuum of care.