Making Health Care Safer for Older Adults Receiving Skilled Home Health Care Services After Hospital Discharge

Care transitions are the movement of a person from one healthcare setting to another. Older adults who require skilled home health care (\"home health\") services (e.g., home-based nursing) after hospital discharge are at high risk of experiencing early re-hospitalization. Home health agencies need strategies to ensure safe transitions, yet there is relatively little research to guide improvement efforts. The goal of the study is to develop and test tools to allow home health agencies to identify and act upon threats to older adults\' safety in real time. The investigators first analyzed threats to older adult safety during hospital-to-home health transitions and refined a bundle of interventions through stakeholder engagement. This prospective pilot will implement and measure the bundle of interventions.