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I-TRANSFER evaluates a protocol for one-week home health and outpatient visits for Medicare sepsis survivors. The work describes ERIC-based implementation strategies across five health systems with needs assessment interviews. Sites modified EHRs to identify patients, strengthened information transfer, and used centralized support and telemedicine to secure timely outpatient care, mapping barriers and solutions to ERIC to guide scalable improvement.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/improving-care-transitions-for-sepsis-survivors-to-home-health-care-the-i-transfer-experience-late-breaking-quality-improvement/428514/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/improving-care-transitions-for-sepsis-survivors-to-home-health-care-the-i-transfer-experience-late-breaking-quality-improvement/428514.png","ImageObject",300,407,{"name":92,"@type":93},"Kurz","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-30","2026-09-29",true,{"@type":102,"interactionType":103,"userInteractionCount":44},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"Why are care transitions critical for sepsis survivors after discharge?","Question",{"text":112,"@type":113},"Older adult sepsis survivors have a high risk of readmission and a median time-to-readmission of 11 days, making timely post-discharge attention essential.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What does the I-TRANSFER experience evaluate?",{"text":117,"@type":113},"I-TRANSFER evaluates implementation and impact of a protocol for timely home health and outpatient visits within one week after discharge for Medicare sepsis survivors.",{"name":119,"@type":110,"acceptedAnswer":120},"How did sites identify sepsis patients and improve follow-up care?",{"text":121,"@type":113},"Sites modified EHRs with alerts and reports, educated providers, and improved documentation; they also secured timely outpatient appointments using centralized support, revised roles, and telemedicine.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},428514,1790790155,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":44,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":14,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":24,"preview_page_count":4},2336478945635,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","Innovation in Aging, 2025, Vol. 9, No. S2 1317  \nSESSION 9135 (PAPER)   \nLATE BREAKING: QUALITY IMPROVEMENT  \nINNOVATIONS IN HEALTH CARE I  \nAbstract citation ID: igaf122.4386  \nIMPROVING CARE TRANSITIONS FOR SEPSIS  \nSURVIVORS TO HOME HEALTH CARE: THE  \nI-TRANSFER EXPERIENCE  \nKathryn Bowles1, Sang Bin You2, Michael Stawnychy1, Nancy Hodgson2, Elaine Sang1, Katherine Pitcher1, Sungho Oh1, and Karen Hirschman2, 1. University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, United States,  \n2. University of Pennsylvania, Philadelphia, Pennsylvania, United States  \nOlder adult sepsis survivors are at high risk for readmission, with a median time-to readmission of 11 days, making timely attention post-discharge critical. However, providing timely post-acute care is difficult partly due to care transition challenges  \n—such as barriers in identifying sepsis, sharing critical information, and activating timely post-acute follow-up. I-TRANSFER evaluates the implementation and impact of a protocol for timely home health (HH) and outpatient visits within one-week post-discharge for Medicare sepsis survivors. Herein, we describe ERIC implementation strategies used to overcome barriers to timely post-acute care during the I-TRANSFER implementation. Five health systems (16 hospitals) in four states partnered on implementation with five HH agencies. Barriers and facilitators identified via needs assessment interviews were coded using thematic analysis. Findings were shared and strategies developed  \n1318 Innovation in Aging, 2025, Vol. 9, No. S2  \nwith implementation teams over 18 months. Strategies were mapped by the research team to the Expert Recommendations for Implementing Change (ERIC) taxonomy. Barriers and strategies were discussed in 36 planning and 145 implementation meetings. To identify sepsis patients, sites modified EHRs (alerts/ reports), educated providers, and improved documentation. For information transfer, strategies included referral flags, reminders, notes, staff education, and securing a new sepsis aftercare ICD-10 code. For timely outpatient care, appointments were achieved using centralized support, revised roles, and telemedicine.  \nImplementation strategies addressed barriers from diagnosis through outpatient follow-up, offering actionable guidance and scalable solutions to enhance hospital-to-home and outpatient transitions for older adults and prevent poor discharge outcomes.  \nMapping to the ERIC taxonomy provides a standardized way to describe the strategies across implementations.","cbCaio3OL82L3nqG","https://ap.wps.com/l/cbCaio3OL82L3nqG","pdf",2275260,"English","# Late Breaking: Quality Improvement\n## I-TRANSFER protocol and target population\n## ERIC implementation strategies (diagnosis, information transfer, follow-up)\n## Findings, mapping, and scalability","[{\"question\":\"Why are care transitions critical for sepsis survivors after discharge?\",\"answer\":\"Older adult sepsis survivors have a high risk of readmission and a median time-to-readmission of 11 days, making timely post-discharge attention essential.\"},{\"question\":\"What does the I-TRANSFER experience evaluate?\",\"answer\":\"I-TRANSFER evaluates implementation and impact of a protocol for timely home health and outpatient visits within one week after discharge for Medicare sepsis survivors.\"},{\"question\":\"How did sites identify sepsis patients and improve follow-up care?\",\"answer\":\"Sites modified EHRs with alerts and reports, educated providers, and improved documentation; they also secured timely outpatient appointments using centralized support, revised roles, and telemedicine.\"}]","IMPROVING CARE TRANSITIONS FOR SEPSIS SURVIVORS TO HOME HEALTH CARE - THE I-TRANSFER EXPERIENCE - Late Breaking: Quality Improvement | PDF",1790646901]