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

Abstract

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. 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. 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. 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. 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. Embedding structured transition workflows and leveraging multidisciplinary collaboration significantly improved care continuity, safety and outcomes for chronic patients transitioning from hospital to home.