HOME, the heart of healing: advancing patient safety beyond the hospital.

HOME, the heart of healing: advancing patient safety beyond the hospital - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Search Log in Primary site navigation Search Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice BMJ Open Qual . 2026 Jun 1;15(2):e003974. doi: 10.1136/bmjoq-2025-003974 HOME, the heart of healing: advancing patient safety beyond the hospital Sultanah Al Harbi 1, ✉ , Nourulhuda Obaidallah 2 , Eidah Aljuaid 3 , Kristin Diamat 1 , Sheeba Selvaraj 1 , Herlene Tolentin 2 , Fatmah Alzobidi 1 , Noorah Alshowaier 4 , Nada Alharthi 4 , Frenk Lee Baldovino 1 , Kamille Bianca Raviz 1 Author information Article notes Copyright and License information 1 Case Management Department, Al Hada Armed Forces Hospital, Taif, Saudi Arabia 2 Home Health Care Department, Al Hada Armed Forces Hospital, Taif, Saudi Arabia 3 Head and Neck Surgery Department, Al Hada Armed Forces Hospital, Taif, Saudi Arabia 4 Physical Therapy Department, Al Hada Armed Forces Hospital, Taif, Saudi Arabia Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise. Additional supplemental material is published online only. To view, please visit the journal online ( https://doi.org/10.1136/bmjoq-2025-003974 ). None declared. ✉ Sultanah Al Harbi; sm.alharbi909@gmail.com Received 2025 Nov 16; Accepted 2026 May 18; Collection date 2026. Copyright © Author(s) (or their employer(s)) 2026. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: https://creativecommons.org/licenses/by-nc/4.0/ . PMC Copyright notice PMCID: PMC13239645  PMID: 42225372 Abstract Background Timely and coordinated care transitions from hospital to home are vital to ensuring patient safety and satisfaction, especially among chronically ill and high-risk patients. Local problem At Armed Forces Hospitals–Taif Region (Kingdom of Saudi Arabia), delays in referral to assessment by home healthcare (HHC) services led to delay in the initiation of HHC falling short of global standards. Objectives This quality improvement project aimed to enhance the transition pathway from hospital to home care and to assess the effect of the intervention on the 30-day readmission rate and patient satisfaction among chronic patients requiring HHC follow-up. Methods This initiative, implemented between September 2024 and June 2025, used the Lean Six Sigma methodology (Define, Measure, Analyse, Improve and Control), the 4P patient experience model and the strength-based clinical case management model to design and implement a structured care transition pathway that included early electronic referral alerts, standardised discharge workflows, predischarge HHC assessments, individualised care plans, transition navigators, centralised coordination, virtual follow-up clinics and weekly multidisciplinary rounds. Results The timely initiation of HHC improved from 51% to 89.4% for high-priority patients and 71% to 92% for low-priority patients through improving referral to HHC initiation prior to discharge, and patient satisfaction increased from 46% to 91%. The average 30-day readmission rate declined from 35.8% to 7.7%. This translated into estimated cost savings of SAR4 960 536–4 982 136 (US$1 322 809–1 328 569), attributed primarily to avoided bed-days for preventable readmissions. There was a decrease in emergency department visits with the monthly average decreasing from 2.2 visits to 1.0 visits, representing a 54.5% reduction. Conclusion Embedding structured transition workflows and leveraging multidisciplinary collaboration significantly improved care continuity, safety and outcomes for chronic patients transitioning from hospital to home. Keywords: Patient safety, Quality improvement, Patient Discharge WHAT IS ALREADY KNOWN ON THIS TOPIC Home healthcare (HHC) services offer vital, cost-effective and satisfactory continuing care for chronically ill patients which helps reduce complications and improve patient health outcomes following hospital discharge. Nevertheless, healthcare systems worldwide suffer delays in initiating HHC services which may be caused in part by limited staffing, insufficient staff training and disorganised communication between hospitals and HHC providers. WHAT THIS STUDY ADDS In this study, we developed a standardised, multidisciplinary, patient-centred, case-management-led, hospital-to-home care transition pathway for chronic patients which used case management models for optimising the workflow, integrated electronic referral systems, developed a role for transition navigators (discharge coordinators), incorporated virtual clinics and focused on patient and caregiver education. This intervention succeeded in decreasing the HHC referral time and reducing the 30-day readmission rate as well as improving patient satisfaction with the service. HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY This project highlights the indispensable role of case management for improving care transition and health outcomes for chronic patients while enhancing the optimal utilisation of hospital resources. Introduction and background Timely transition of healthcare from hospital to home is a key quality indicator in health systems. Home healthcare (HHC) plays a critical role in supporting patient recovery, reducing hospital readmissions and ensuring continuity of care after discharge. This timely follow-up is essential for early detection of complications, medication reconciliation, care planning and patient education. International guidelines commonly use a 7-day benchmark to define a complete HHC referral, which means initiating HHC services within 7 days of hospital discharge. 1 The Ministry of Health of Saudi Arabia determines that hospitals must refer eligible patients to HHC services at least 72 hours prior to discharge and that an initial home visit must occur within 1 week of discharge. 2 However, many health systems continue to face significant challenges in meeting these time frames. Systemic barriers including poor interagency communication, inadequate staffing and limited digital infrastructure contribute to delays in postdischarge follow-up. 3 These delays are associated with increased emergency department (ED) visits and preventable hospital readmissions, thus compromising patient safety. 4 Problem description Within our healthcare setting in the Kingdom of Saudi Arabia (KSA), the challenge is equally apparent. There is a significant delay in the transition of patient care from the hospital to home. Our data during the third quarter of 2024 revealed that the time between HHC referral and the first assessment by HHC services occurred at an average of 4 days after discharge, which resulted in a reduction of the success of HHC initiation to 51% for high-priority patients and 71% for low-priority patients. This gap underscored the urgent need for quality improvement initiatives to enhance the care transition pathway. Available knowledge HHC represents a pivotal shift in the delivery of health services, allowing individuals to receive medical care and support within the comfort of their homes. This model is being increasingly recognised worldwide as a viable alternative to institutional care; this is driven by various socioeconomic factors, including population ageing, a growing prevalence of chronic diseases and a pressing demand for cost-effective health services. HHC can provide comprehensive patient support ranging from skilled nursing to rehabilitative services. It is a practical solution for managing healthcare costs while maintaining patient satisfaction and quality of life. 5 Health facilities in Europe and the USA have extensively adopted HHC services to facilitate ageing in place, thus improving the quality of life for older adults while reducing hospital readmissions and associated healthcare costs. 6 The HHC sector in the KSA is also experiencing growth. The health transformation goals of the Kingdom’s Vision 2030 comprise enhancing the healthcare infrastructure and services which facilitate better management of chronically ill patients at home. There is rising demand for improved HHC services to cater for an ageing population and the rising incidence of non-communicable diseases in the Kingdom. 7 However, like many other countries, Saudi Arabia faces challenges in effectively integrating these services into a coherent healthcare system. 8 Despite the benefits of HHC, numerous challenges impact its efficacy and accessibility. Key barriers include inadequate workforce capacity; HHC providers often struggle with limited staffing capabilities, resulting in compromised patient care and increased workload of the available care providers. 9 10 Furthermore, insufficient training of HHC staff diminishes the skills they should possess to manage patients at home, resulting in poorer patient outcomes. 11 Disorganised communication between hospitals and HHC providers also poses a significant barrier which often leads to incomplete referrals and inadequate follow-up. 11 In Saudi Arabia, these challenges are compounded by cultural factors, a nascent HHC system, defective stakeholder engagement and insufficient educational programmes for healthcare providers and patients. 12 In conclusion, while HHC offers significant benefits for patients and healthcare systems, numerous challenges must be addressed to maximise its potential. Rationale The absence of standardised workflows for effective hospital-to-home care transition often leads to defective communication, inadequate patient/caregiver education and preventable readmissions. 13 In this study, we sought to develop an evidence-based intervention specific to chronic patients in need of HHC, targeting the improvement of healthcare delivery while optimising healthcare resources and enhancing patient health outcomes and experience. Specific aim The primary objective of this initiative was to streamline the transition of chronic patients from hospital to home care via improving the timely initiation of HHC from 51% to 80% between September 2024 and June 2025. The secondary objective was to evaluate the impact of our intervention on the 30-day readmission rate and on satisfaction of those patients. Methods Context Armed Forces Hospitals–Taif Region (including Al Hada Armed Forces Hospital, Prince Mansour Military Hospital, Prince Sultan Hospital and the Armed Forces Rehabilitation Center) are pivotal in delivering comprehensive health services in Taif (Makkah Region, Saudi Arabia). Within its expanding portfolio of services, HHC has emerged as a vital component for supporting the continuity of care for patients with chronic illnesses, postsurgical needs and palliative/rehabilitative support after hospital discharge. Despite commitment to excellence, ensuring timely and seamless patient transition from hospital to home care remained a challenge. Referral to HHC services, provided by the Armed Forces Rehabilitation Center, was found to be initiated by an average of 4.3 days after discharge (instead of before discharge); the average time for initiation of HHC services was delayed to 7 days following discharge; the timely initiation of HHC services was only 51% for high-priority patients and 71% for low-priority patients; patient satisfaction with the quality of the hospital-to-home care transition pathway was as low as 46%; and the 30-day readmission rate among patients followed by HHC was 13.6%. Thus, this quality improvement project was set to enhance the efficiency of the hospital-to-HHC care transition pathway, with enhancing patient outcomes and optimising the utilisation of health resources at the heart of the intervention. Intervention This project employed a multidisciplinary case management approach. The multidisciplinary performance improvement team comprised the director of the case management department; case managers; representatives from HHC, pharmacy, nursing and medical administration (including primary care physicians); social workers; materials management department personnel; and a continuous quality improvement and patient safety (CQI & PS) coach. To redesign the hospital-to-home care transition pathway, the Lean Six Sigma methodology (Define, Measure, Analyse, Improve and Control (DMAIC)) 14 was used. Value stream mapping was used to visualise each step of the transition pathway ( online supplemental figure 1 ). Shadowing was conducted to analyse the discharge process and map value-added and non-value-added (NVA) steps from when a patient is ready for discharge until the initiation of HHC services ( online supplemental table 1 ). NVA steps were responsible for 58% of the process time, reflecting the areas indicated for improvement, particularly referrals and HHC patient assessment schedules and visits. Root cause analysis identified the key contributing factors for the ineffective transition process, including inconsistent involvement of case management staff, unclear or complex care coordination workflows and a reliance on manual referral processes ( online supplemental figure 2 ). Specific delay points were mapped to critical steps such as finalising discharge instructions and communication with the HHC department resulting in delay of the first HHC visit. The 4P model for patient experience 15 was used to guide optimisation of the care transition process and to identify the areas for improvement ( online supplemental figure 3 ). Moreover, the following case management strategies were adopted for designing the intervention: the strength-based clinical case management model 16 ; the framework for safe, reliable and effective care 17 ; and the social entrepreneurship model. 18 Together, these methodologies provide a structured evidence-based approach to redesigning the care transition pathway ( online supplemental figure 4 ). A standardised hospital-to-home pathway was developed to guide the care transition process ( online supplemental figure 5 ). The intervention addressed 170 chronic patients (24–103 years old, both male and female) eligible for HHC services, that is, medically stable patients, free from substance abuse, living within a 25 km radius from the hospital and with a home caregiver (relative) suitably educated to provide care. In terms of medical criteria, the patients were at least one of the following: bedbound due to any medical condition; using wheelchairs; on palliative care for end-stage diseases; suffering moderate to severe dementia; or requiring invasive respiratory devices. Patients were categorised by priority depending on the clinical judgement of HHC physicians as dictated by the internal benchmarks of our institution. Among the 170 patients, 83 were categorised as high priority (ie, patients in need of urgent care to be seen within five business days of discharge, including bedridden patients and patients on ventilation); the remaining 87 patients were low priority (ie, stable patients whose medical condition allowed for a visit within 30 days of discharge). Four patients died during the course of the intervention. A major focus of the intervention was developing a role for the transition navigator (discharge coordinator). A standardised Transition Navigator Checklist was developed ( online supplemental figure 6 ) which served as a cognitive aid and accountability tool to ensure that all critical elements of the discharge process (eg, medication reconciliation, caregiver education, home visit scheduling) were completed before discharge. This reduced the variability in discharge practices and enabled the identification of referral oversights. In addition, a dedicated centralised transition coordination team (comprising case managers and transition navigators) was established to oversee the end-to-end referral process and ensure a single point of contact for hospital and HHC teams. The manual, paper-based home care referral process was substituted with an automated electronic referral system integrated within the electronic medical record (EMR) platform. This allowed for time-stamped documentation of referrals and decreased transcription errors in addition to ensuring real-time access of the HHC coordination team to referrals, enabling same-day triage and earlier scheduling of home visits. Moreover, automated referral alerts were integrated into the EMR to flag patients eligible for HHC at admission for proactive discharge planning and minimising referral delays. Patient assessment by the HHC team was moved to the predischarge period (instead of postdischarge). This advance assessment minimised coordination gaps and allowed for proactive mobilisation of the necessary services. The intervention also involved a virtual follow-up clinic which provided telephonic and video-based consultations within 48 hours of discharge for patients awaiting HHC home visits. This ensured continuity of care, reduced early complications and reassured patients/families during the vulnerable postdischarge period. Patient and caregiver education was also a core element of the intervention. Prior to discharge, health educators and transition navigators provided patient education on several topics including medication reconciliation, warning signs and red flags, device and equipment use, when and how to seek emergency care and follow-up appointments. Teach-back was used to verify comprehension. Furthermore, reinforcement education was delivered after discharge via virtual follow-up clinics and home health visits. Education for caregivers comprised structured sessions covering medication management; monitoring for clinical deterioration (and timely contact of healthcare providers or seeking emergency care); hands-on training in activities of daily living; safe patient transfers and use of assistive devices; wound care and infection-prevention measures; nutrition support and fluid management; coordination of follow-up appointments and communication with the HHC team; and caregiver self-care strategies (including stress management and access to respite and community resources). Education was delivered during home visits using demonstration, teach-back methods and written and/or video materials. To sustain the gains of the intervention, robust control measures were embedded into routine operations including performance dashboards, monthly audits of referral times and discharge compliance and ongoing staff training sessions. Staff were encouraged to provide suggestions and report operational barriers. The details of the intervention are outlined in online supplemental table 2 . Patient and public involvement Patient and family-related factors substantially influenced the hospital-to-home care transition pathway targeted for improvement in this project. Consequently, patients and their families were actively engaged in the design and implementation of the intervention, with multiple solutions tailored to address their needs throughout the process. Study of the interventions This initiative adopted the DMAIC model to redesign the discharge workflow. Patient satisfaction data were collected via questionnaires facilitated by case managers and transition navigators. Other data were collected retrospectively from the case management department database, the HHC registry and via patient surveys and shadowing during transition navigator rounds. Data were also collected from the hospital information system (WIPRO) on a weekly and monthly basis. Collected data were initially validated by the CQI & PS department after which 10% of the data were randomly selected and independently validated by other parties. If the results exceeded 90%, the data were considered valid. Constant monitoring and evaluation were performed throughout the project, according to which decisions were made either to adapt or adjust/discard the intervention. Measures Process measures The process measures were selected based on their direct relevance to the desired outcomes: percentage of adherence to HHC referral as per discharge instructions in the Transition Navigator Checklist, percentage of documenting the assessment and care plan, percentage of patient enrolment to HHC services and the referral to HHC initiation interval (days) ( online supplemental table 2 ). Outcome measures Patient satisfaction (Care Transitions Measure-15) Patient satisfaction with care transition from hospital to home was assessed using the Care Transitions Measure-15 (CTM-15) questionnaire 19 ( online supplemental figure 7 ). It is one of the most widely used patient-reported questionnaires; the score (0–100) reflects the quality of care transition from the patient’s perspective, with lower scores indicating a poorer quality and higher scores indicating a better transition. The questionnaire was facilitated by case managers and HHC nurses 5 days to 5 weeks after discharge. Timely initiation of HHC This represents the percentage of patients newly accepted by HHC services who have actually been visited by HHC personnel within five business days of acceptance for high-priority patients and within 30 days of acceptance for low-priority patients (as outlined earlier). 30-day readmission rate This is the percentage of discharged patients who were readmitted to any hospital within 30 days of their initial discharge while receiving follow-up care from the HHC provider. The operational definitions of the process and outcome measures are outlined in online supplemental table 3 . Analysis The primary process measures were represented via line charts with trend lines. A combination of scatter diagram and line chart with trend lines was used for presenting outcome measures. In addition, a scatter chart was used to compare the timely initiation of care for high-priority and low-priority patients. The Lean Six Sigma DMAIC model involved shadowing to enable the identification of stages that could be enhanced to improve the care transition process. Value stream mapping was used to visually represent the care transition pathway before and after the intervention. Furthermore, patient satisfaction was measured and analysed via surveys. Ethical considerations This quality improvement initiative involved enhancements to the existing routine services (including patient satisfaction surveys, as part of the routine evaluation). According to institutional policy, such quality improvement initiatives do not require ethical review. Results Process measures The percentage of adherence to HHC referral as per discharge instructions increased throughout the initiative. The results rapidly increased from 28% at the start of implementation (September 2024) to 71% in October 2024, reaching the target (75%) in December 2024. This was followed by a gradual sustainable increase until the end of the initiative (June 2025) with an average of 97% ( figure 1a ). After a rapid increase from 29% at the beginning of the initiative to 93% in October 2024, there was a sustainable improvement in the percentage of documenting individualised assessment and care plans for the targeted patients. The results improved from an average of 31.7% to 95.7% after implementation ( figure 1b ). Figure 1c shows an average gradual sustainable improvement in the percentage of patients enrolled to HHC. The percentage increased from an average of 69% to 80.2% at the end of the project. Finally, figure 1d displays the remarkable improvement in the referral to HHC initiation interval. The waiting time from the referral date to the initial assessment by HHC improved from an average of 4.3 days after discharge to −1.3 days (prior to discharge) at the end of the initiative. Figure 1. Process measures. Line charts with trend lines showing process measure values before and after the intervention. (a) Adherence to documented discharge instructions (%). (b) Documented case management individualised assessment and care plan (%). (c) Patients enrolled in home healthcare (HHC) services. (d) HHC referral initiation interval (days). Ave, average. Open in a new tab Outcome measures Patient satisfaction, as defined by the CTM-15 score ( figure 2a ), exhibited a remarkable improvement from an average of 46% before the initiative to 91% at the end of June 2025. Figure 2b displays the sustained improvement in the timely initiation of care for patients of both low priority (71–92%) and high priority (51–89.4%), exceeding the 80% target. In addition, there was a striking 78% reduction in the 30-day readmission rate among patients followed up by HHC, from an average of 35.8% before implementation to 7.7% at the end of June 2025. The target was achieved in the second quarter of 2025. Figure 2. Outcome measures and ED visits. (a) Patient satisfaction using CTM-15 score (%) before and after the intervention. (b) Timely initiation of HHC for HP and LP patients before and after the intervention. (c) 30-day readmission rate (%) before and after the intervention. (d) ED visits (%) of patients followed by HHC before and after the intervention. Ave, average; CTM-15, Care Transitions Measure-15; ED, emergency department; HHC, home healthcare; HP, high priority; LP, low priority. Open in a new tab The preintervention and postintervention values are presented in table 1 . Table 1. Project measures, baseline versus postintervention. Measure Baseline Target Postintervention P value * Process measures Adherence to HHC referral as per discharge instructions (%) 25.7 >75.0 97.0 0.002 Documenting assessment and care plan (%) 31.7 >75.0 95.7 0.002 Patient enrolled in HHC services (%) 69.0 >75.0 80.2 0.002 Referral initiation interval (days) 4.3 <1 −1.3 0.002 Outcome measures Patient satisfaction (CTM-15 score) (%) 46.0 >75.0 91.0 0.002 Timely initiation of HHC (%) For high-priority patients 51.0 80.0 89.4 0.002 For low-priority patients 71.0 80.0 92.0 0.002 30-day readmission rate (%) 35.8 <5.0 7.7 0.002 Open in a new tab Bold values are significant. * Significant at p<0.05. CTM-15, Care Transitions Measure-15; HHC, home healthcare. Unintended consequences The study positively impacted ED visits for patients followed by HHC. There was a remarkable reduction in the percentage of ED visits by 54.5%. ED visits were reduced from an average of 2.2 monthly visits (pre-implementation) to one average monthly visit (post implementation) until the end of June 2025 ( figure 2d ). Economic impact: estimation of cost savings We considered the reduction in the length of stay (LOS) associated with avoided readmissions as a parameter to estimate the cost savings of the project. An average LOS of 10–14 days per admission 20 and an estimated cost of SAR2500–4500 per bed-day 21 have been reported in Saudi Arabia. The 30-day readmission rate was reduced by 28.1% (from a preintervention value of 35.8% to 7.7% postintervention), which was translated into 35 avoided readmissions for the 170 subjects targeted by our interventions. Using a period of 12 days as the average LOS per readmission and a conservative cost of SAR3000 per bed-day, the 35 readmissions avoided during this project resulted in estimated cost savings of SAR1 260 000 (US$335 960). The direct cost of avoidable ED visits ranges from SAR2000 to SAR4000 per visit. 22 23 The number of ED visits was reduced from 2.2 to 1.0 per month by the end of our intervention, resulting in avoiding 1.2 ED visits a month and a total of 10.8 avoided ED visits during the 9-month period of this initiative. Therefore, the study is estimated to have saved between SAR21 600 (US$5759) and SAR43 200 (US$11 519) in direct ED costs across the postintervention period. Extra cost savings came from two key improvements: first, by initiating HHC care more quickly, the project avoided 51 bed-days, and second, by speeding up the referral process, patients spent 5.6 fewer days in hospital. With a benchmark cost of SAR3668 for inpatient bed per day in Saudi Arabia, 24 these resulted in savings of SAR187 068 and SAR3 491 936, respectively. Combined, these improvements led to total savings of SAR4 960 536–4 982 136 (US$1 322 809–1 328 569). While the economic value of some factors (eg, healthcare worker time saved, reduced caregiver burden, improved patient quality of life) cannot be precisely quantified, it is reasonable to conclude that the intervention has led to meaningful indirect cost savings and substantial improvements in both patient outcomes and healthcare system efficiency. Discussion Summary This quality improvement project focused on enhancing the care transition of chronic patients from hospital to home at Armed Forces Hospitals–Taif Region, Saudi Arabia. The project interventions resulted in a reduced referral to HHC assessment interval from 4.3 days after discharge to 1.3 days prior to discharge, increased patient satisfaction scores from 46% to 91% and decreased the 30-day readmission rate from 35.8% to 7.7%. Additional outcomes included improved documentation, better team coordination and a 16.3% reduction in ED visits. The findings of this project underscore the critical role of timely referral and initiation of HHC services in enhancing patient outcomes and satisfaction and reducing avoidable burdens to the healthcare system. Integrating transition navigators and developing a standardised hospital-to-home care pathway led to marked improvements across multiple process and outcome measures. These findings demonstrate that a structured, patient-centred approach can optimise hospital-to-home care transition and improve care continuity and outcomes for chronic patients. Interpretation The gains of this work resulted from the creation of a standardised hospital-to-home care transition pathway integrating a multidisciplinary approach and a role for transition navigators. Transition navigators led the way by implementing and continuously monitoring the introduced strategies. Consistent improvement of the process measures impacted our outcomes and resulted in a remarkable decrease in the percentage of ED visits made avoidable by the convenient design and application of this quality improvement project. The utilisation of evidence-based case management models was cornerstone in the success of the intervention. By integrating the 4P model into workflows, hospitals can mitigate transition risks and enhance outcomes, as evidenced by a 27% reduction in readmissions in pilot studies. 15 Structured interventions and follow-up (eg, teach-back discharge education) improve comprehension, while standardised processes reduce provider communication errors. 25 Engaging patients and caregivers through training and tools empowers self-management, and collaboration with partners (eg, HHC agencies) ensures continuity of care. 26 27 Our project achieved a substantial reduction (of 6.7 days) in the referral to HHC initiation interval compared with previous interventions, including a 2–3 days’ improvement reported by Levine et al. 28 Moreover, we reported a 28.1% reduction in readmissions for patients transitioned to HHC, which compares to other studies highlighting the benefits of embedding transition navigators into the discharge workflow, including the work by Mohamed et al , who reported a 5% reduction in readmissions. 29 One of the key innovations of this intervention was the use of early-discharge referral alerts. These alerts helped identify patients eligible for HHC earlier in their hospital stay, enabling the care team to initiate referral before discharge. This proactive approach ensured that patients received timely follow-up care and that the care transition from hospital to home was smoother and more efficient. The benefits of electronic referrals for supporting discharge processes have been previously demonstrated by Bowles et al. 30 In contrast to studies that primarily focus on postdischarge follow-up, this project places stronger emphasis on predischarge workflow optimisation, highlighting a gap in the literature that this project helps address. While most of our previous interventions began after hospital discharge, care coordination in our intervention was initiated during hospitalisation which led to better discharge preparedness. Several studies have emphasised the benefits of timely HHC initiation. Smith et al highlighted that initiation of HHC services within 48 hours of discharge reduced readmission rates in older adults with multiple chronic conditions. 31 Similarly, Ritchie and Leff reported that delayed postdischarge HHC services are associated with an increased risk of hospital readmissions and poorer patient satisfaction. 32 Our project also contributes novel insights into process efficiency, showing that case management engagement and improvement in documentation practices are strongly linked with outcome metrics, particularly patient satisfaction and ED use. These findings align with those of David and Kim, 33 which emphasise that care coordination interventions are most effective when integrated into routine hospital workflows and are led by dedicated transition personnel. This project stresses that the timing of referral/initiation of HHC is not merely administrative—it is a patient safety issue. This project provides a model for institutions aiming to improve the safety and efficiency of hospital-to-home care transitions. Limitations Despite the valuable insights generated by this project, it is important to affirm that the outcomes were assessed within a limited postdischarge period, which may not fully reflect the long-term impacts of the initiative on patient health and readmission rates. Future studies incorporating longer follow-up windows are necessary to assess the durability of the observed improvements. Furthermore, mortality data were not included in this study. As a result, our analysis might have overlooked critical outcomes that could influence the effectiveness and safety of the modified transition process. Another limitation is that our target patients were categorised as ‘high priority’ and ‘low priority’, which is a classification that meets only our institutional benchmarks. The Lean approach implemented in this initiative focused mainly on high-priority patients which might have resulted in disparities in patient prioritisation and potentially compromised equity and care to low-priority patients. Furthermore, the preintervention and postintervention design of this study did not include a control group since this multisite project prioritised rapid, ethical rollout of improvements to all eligible patients, avoiding inequities or risks from withholding interventions. Nevertheless, lack of a control group may have limited inference of causality of our findings and potentially confounded the results with external factors. Future efforts should use staggered implementations for quasicontrols. In addition, HHC services experienced staffing shortages during the study period, which increased the burden on existing staff and may have impacted the timeliness and quality of care delivered. Furthermore, logistical challenges, including delays in transportation and scheduled home visits, may have led to variability in the continuity and immediacy of postdischarge care. This study was conducted only within Armed Forces Hospitals of Taif (Saudi Arabia) which possess a specific range of resources, workflows and technological infrastructure. As such, the generalisability of findings to other health systems or regions with differing HHC capacities may be limited. Conclusions This study highlights the transformative impact of a structured, multidisciplinary approach in streamlining the care transition of chronic patients from hospital to home. Implementing the patient-centred 4P model, comprehensive care planning; standardised workflows; coordination among case managers, transition navigators, physicians and HHC teams; and early referral alerts strengthened the continuity of care and advanced the safety and satisfaction of chronic patients requiring HHC across the transition journey. Due to the remarkable impact of this improvement, it has been recommended that this set of interventions be disseminated to other Armed Forces Hospitals in the KSA. The success of this model provides a strong foundation for scaling similar interventions across other healthcare settings, ensuring that patients receive timely, safe and compassionate care beyond the hospital door. Supplementary material online supplemental file 1 bmjoq-15-2-s001.docx (8.1MB, docx) DOI: 10.1136/bmjoq-2025-003974 Acknowledgements We extend our heartfelt gratitude to Dr Ahmed Mohammed Al Amri, the CEO of the Health Services Directorate of Saudi Arabia, for his unwavering support and guidance in enhancing the cancer case management pathway within our healthcare system. We also express our appreciation to Dr Noura Alnowaiser, Executive Healthcare Quality Director, and Colonel Dr Yasser Alotaibi, Deputy Director of Quality Improvement and Patient Safety at the Ministry of Defense Health Division, for their guidance and unwavering support throughout this transformative journey. Furthermore, we extend our thanks to all clinical staff who played a pivotal role in ensuring the success of this intervention. Footnotes Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Provenance and peer review: Not commissioned; externally peer reviewed. Patient consent for publication: Not applicable. Patient and public involvement: Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details. Data availability statement No data are available. References 1. Demiralp B, Speelman JS, Cook CM, et al. Incomplete Home Health Care Referral After Hospitalization Among Medicare Beneficiaries. J Am Med Dir Assoc. 2021;22:1022–8. doi: 10.1016/j.jamda.2020.11.039. [ DOI ] [ PubMed ] [ Google Scholar ] 2. Ministry of Health, Kingdom of Saudi Arabia Home health care services. 2018. [31-Jul-2025]. https://www.moh.gov.sa/en/awarenessplateform/Patientsrights/Pages/HomeHealthCare.aspx Available. Accessed. 3. Okoniewska B, Santana MJ, Groshaus H, et al. Barriers to discharge in an acute care medical teaching unit: a qualitative analysis of health providers’ perceptions. J Multidiscip Healthc. 2015;8:83–9. doi: 10.2147/JMDH.S72633. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 4. Micallef A, Buttigieg SC, Tomaselli G, et al. Defining Delayed Discharges of Inpatients and Their Impact in Acute Hospital Care: A Scoping Review. Int J Health Policy Manag. 2022;11:103–11. doi: 10.34172/ijhpm.2020.94. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 5. Werner RM, Kim S, Konetzka RT. Trends in Home Health Care Among Traditional Medicare Beneficiaries With or Without Dementia. JAMA Netw Open . 2025;8:e2510933. doi: 10.1001/jamanetworkopen.2025.10933. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 6. Cheng M, Lin L, Cao X, et al. Effectiveness of admission-avoidance hospital at home as alternative to routine hospital care in older adults: a systematic review and meta-analysis. Global Transitions . 2025;7:342–9. doi: 10.1016/j.glt.2025.06.002. [ DOI ] [ Google Scholar ] 7. Asgari P, Dehghan Nayeri N, Bahramnezhad F, et al. When Technology Enters at Home: The Challenges of Home Health Care Providers in a Developing Country. Crit Care Nurs Q. 2021;44:379–86. doi: 10.1097/CNQ.0000000000000374. [ DOI ] [ PubMed ] [ Google Scholar ] 8. Molloy MA, Cary MP, Jr, Brennan-Cook J, et al. Preparing Clinicians for Transitioning Patients Across Care Settings and Into the Home Through Simulation. Home Healthc Now. 2018;36:225–31. doi: 10.1097/NHH.0000000000000667. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 9. Sobotka SA, Gaur DS, Goodman DM, et al. Pediatric patients with home mechanical ventilation: The health services landscape. Pediatr Pulmonol. 2019;54:40–6. doi: 10.1002/ppul.24196. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 10. Narayan MC, Mallinson RK. Home Health Nurses’ Journey Toward Culture-Sensitive/Patient-Centered Skills: A Grounded Theory Study. Home Health Care Manag Pract. 2022;34:24–34. doi: 10.1177/10848223211027860. [ DOI ] [ Google Scholar ] 11. Damery S, Flanagan S, Jones J, et al. The Effect of Providing Staff Training and Enhanced Support to Care Homes on Care Processes, Safety Climate and Avoidable Harms: Evaluation of a Care Home Quality Improvement Programme in England. Int J Environ Res Public Health. 2021;18:7581. doi: 10.3390/ijerph18147581. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 12. Alshammari M, Duff J, Guilhermino M. Barriers to nurse-patient communication in Saudi Arabia: an integrative review. BMC Nurs. 2019;18:61. doi: 10.1186/s12912-019-0385-4. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 13. Markiewicz O, Lavelle M, Lorencatto F, et al. Threats to safe transitions from hospital to home: a consensus study in North West London primary care. Br J Gen Pract. 2020;70:e9–19. doi: 10.3399/bjgp19X707105. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 14. Monday LM. Define, Measure, Analyze, Improve, Control (DMAIC) Methodology as a Roadmap in Quality Improvement. Glob J Qual Saf Healthc. 2022;5:44–6. doi: 10.36401/JQSH-22-X2. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 15. Kash BA, McKahan M, Tomaszewski L, et al. The four Ps of patient experience: A new strategic framework informed by theory and practice. Health Mark Q. 2018;35:313–25. doi: 10.1080/07359683.2018.1524598. [ DOI ] [ PubMed ] [ Google Scholar ] 16. Stoerkel E. What is a strength-based approach? (incl. examples & tools) 2018. [19-Oct-2025]. https://positivepsychology.com/category/strengths-virtues/ Available. Accessed. 17. Frankel A, Haraden C, Federico F, et al. Cambridge, MA: Institute for Healthcare Improvement and Safe & Reliable Healthcare; 2017. [19-Oct-2025]. A framework for safe, reliable, and effective care. White paper. https://www.ihi.org/library/white-papers/framework-safe-reliable-and-effective-care Available. accessed. [ Google Scholar ] 18. García-Jurado A, Pérez-Barea JJ, Nova RJ. A New Approach to Social Entrepreneurship: A Systematic Review and Meta-Analysis. Sustainability. 2021;13:2754. doi: 10.3390/su13052754. [ DOI ] [ Google Scholar ] 19. Coleman EA, Mahoney E, Parry C. Assessing the quality of preparation for posthospital care from the patient’s perspective: the care transitions measure. Med Care. 2005;43:246–55. doi: 10.1097/00005650-200503000-00007. [ DOI ] [ PubMed ] [ Google Scholar ] 20. Temsah M-H, Abouammoh N, Al-Eyadhy A, et al. Predictors and Direct Cost Estimation of Long Stays in Pediatric Intensive Care Units in Saudi Arabia: A Mixed Methods Study. Risk Manag Healthc Policy. 2021;14:2625–36. doi: 10.2147/RMHP.S311100. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 21. Mehmood A, Ahmed Z, Ghilan K, et al. Inpatient Case-mix Cost Vs Average Cost for Health Care Services in King Fahd Central Hospital, Saudi Arabia: A Comparative Study. Inquiry. 2021;58:469580211056060. doi: 10.1177/00469580211056060. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 22. Saudi Health Council . General Directorate of National Health Economics and Policies: National Health Economics Department & National Health Information Center; 2023. [28-Oct-2025]. National health accounts Kingdom of Saudi Arabia: 2022–2023. https://shc.gov.sa/Arabic/NewStrategyDepartment/NationalAccountsDocx/National%20Health%20Accounts-%202022-2023.pdf Available. Accessed. [ Google Scholar ] 23. Roemer M. Rockville, MD: Agency for Healthcare Research and Quality; 2021. [24-Aug-2025]. Cost of treat-and-release emergency department visits in the United States. Statistical Brief #311. https://hcup-us.ahrq.gov/reports/statbriefs/sb311-ED-visit-costs-2021.pdf Available. accessed. [ Google Scholar ] 24. Doss SM, Bergum B, Hopkins L, et al. Transforming Transitional Care: Early Hospital Discharge through the Care at Home Program. J Am Med Dir Assoc. 2025;26:105681. doi: 10.1016/j.jamda.2025.105681. [ DOI ] [ PubMed ] [ Google Scholar ] 25. Lindblom S, Ytterberg C, Flink M, et al. The Use of Teach Back at Hospital Discharge to Support Self-Management of Prescribed Medication for Secondary Prevention after Stroke-Findings from A Feasibility Study. Healthcare (Basel) 2023;11:391. doi: 10.3390/healthcare11030391. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 26. Hickmann E, Richter P, Schlieter H. All together now - patient engagement, patient empowerment, and associated terms in personal healthcare. BMC Health Serv Res. 2022;22:1116. doi: 10.1186/s12913-022-08501-5. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 27. Sharma AE, Rivadeneira NA, Barr-Walker J, et al. Patient Engagement In Health Care Safety: An Overview Of Mixed-Quality Evidence. Health Aff (Millwood) 2018;37:1813–20. doi: 10.1377/hlthaff.2018.0716. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 28. Levine DM, Ouchi K, Blanchfield B, et al. Hospital-Level Care at Home for Acutely Ill Adults: a Pilot Randomized Controlled Trial. J Gen Intern Med. 2018;33:729–36. doi: 10.1007/s11606-018-4307-z. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 29. Mohamed M, Al-Tehewy M, Hakim S, et al. Studying impact of home health care on hospital readmission rate in prince sultan military medical city, Riyadh, Saudi Arabia. Int J Med Health Res. 2020;6:16–21. [ Google Scholar ] 30. Bowles KH, Chittams J, Heil E, et al. Successful electronic implementation of discharge referral decision support has a positive impact on 30- and 60-day readmissions. Res Nurs Health. 2015;38:102–14. doi: 10.1002/nur.21643. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 31. Smith JM, Lin H, Thomas-Hawkins C, et al. Timing of Home Health Care Initiation and 30-Day Rehospitalizations among Medicare Beneficiaries with Diabetes by Race and Ethnicity. Int J Environ Res Public Health. 2021;18:5623. doi: 10.3390/ijerph18115623. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 32. Ritchie CS, Leff B. Population Health and Tailored Medical Care in the Home: the Roles of Home-Based Primary Care and Home-Based Palliative Care. J Pain Symptom Manage. 2018;55:1041–6. doi: 10.1016/j.jpainsymman.2017.10.003. [ DOI ] [ PubMed ] [ Google Scholar ] 33. David G, Kim KL. The effect of workforce assignment on performance: Evidence from home health care. J Health Econ. 2018;59:26–45. doi: 10.1016/j.jhealeco.2018.03.003. [ DOI ] [ PubMed ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials online supplemental file 1 bmjoq-15-2-s001.docx (8.1MB, docx) DOI: 10.1136/bmjoq-2025-003974 Data Availability Statement No data are available. Articles from BMJ Open Quality are provided here courtesy of BMJ Publishing Group ACTIONS View on publisher site PDF (922.4 KB) Cite Collections Permalink RESOURCES Similar articles Cited by other articles Links to NCBI Databases Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top

Related documents

• Patient Safety Culture And Hospital Performance: Patient Safety Outcomes And Patient Rights In Public Traditional Chinese Medicine Hospitals In Sichuan Province, China#352729
• Cure as medicine’s constitutive aim: a defence of the refined curative thesis#130655
• Philosophy, medicine and health care – where we have come from and where we are going#749358
• The Pandemic Dilemma: When Philosophy Conflicts with Public Health#740734
• Joy in Work, Resilience Capacity, and Patient Safety Culture Among Healthcare Professionals In-hospital#1163863