Picture this: a 68-year-old with heart failure leaves the hospital with a new water pill, a changed medication list, and loose advice to see her primary care doctor. Two weeks later, she is back in the emergency department, overloaded with fluid and unsure which pills to take. This gap shows up every day. More hospital days will not fix it. Skilled nursing and rehabilitation need to start at home, with clear follow-up in the first week. Teams need a practical checklist, clear ownership at each handoff, and a short scorecard to track results. The details below work across health systems, with local notes for Australia and New Zealand.