Background: Case Managers (CM) are now a standard presence in emergency departments (ED) of large hospitals, partnering with ED and Hospital Medicine providers to improve care. They are integral in improving hospital throughput and reducing unnecessary hospital admissions and readmissions. Case Managers generally identify high-risk patients using a manual chart review process or by provider [...]

Background: Inter-hospital transfers are integral to a functioning health care network. Critical access, rural, and community hospitals established in sparsely populated territories are unable to support tertiary care infrastructure and rely on academic centers for consultation and transfer. Transfers comprise an estimated 3.5% of inpatient admissions (1), owing in part to increased procedural specialization concentrated [...]

Background: Successful discharge practices and avoidance of readmission requires attention to social needs and care coordination with outpatient care providers. While national programs have attempted to identify interventions within the care continuum to prevent readmission, these programs rarely involve inpatient hospitalists. While robust requirements for certain care transitions processes such as medication reconciliation and discharge [...]

Background: Our region has the lowest hospital bed per capita of any metropolitan area in the United States. Additionally, during the COVID-19 pandemic there have been outpatient dialysis chair shortages due to workforce staffing issues. This has led to many patients waiting weeks or even months in the hospital to secure a new chair for [...]

Background: In November 2021, we initiated a project to improve our length of stay (LOS) and plan of care for patients with a LOS of ≥6 days. We created the Complex Cases Rounds (CCRs) for all patients hospitalized under the hospital medicine service in our community hospital, Emory Johns Creek Hospital. Purpose: CCRs provide a [...]

Background: Our Hospital (Two Campuses A and B) is a part of Yale New Haven Health System (YNHHS). YNHHS is a nonprofit healthcare system in New Haven, Connecticut. Average length of stay (ALOS) for inpatients at Bridgeport Hospital remains longer than the national average. With the recent acquisition of another campus, inpatient volume at our [...]

Background: Adverse events (AE) are common during care transitions (19-28%) in patients with multiple chronic conditions (MCC) and often lead to unanticipated healthcare resource utilization after discharge. While early indicators of these AEs include new and worsening symptoms, systematic monitoring of patient-reported symptoms is lacking. The 21st Century Cures Act mandates the healthcare industry to [...]

Background: Timely, effective follow-up after hospital discharge can improve the efficiency and outcomes of care by increasing hospital throughput and decreasing readmissions and other adverse events after discharge. The University of Chicago Medical Center (UCMC) has chronic bed shortages and a medically and socially complex patient population that makes optimal management of post-discharge care especially [...]

Background: Consumer satisfaction is largely dependent on convenience, efficiency, and quality, and healthcare is no outlier. Technological advancements, such as the use of artificial intelligence or virtual visit appointments, is emerging as a new form of healthcare provided. While these technologies have existed far before the COVID-19 pandemic, it has expedited the mass population’s acclimation [...]

Background: Avoiding preventable readmissions is a major goal of health care systems nationwide1. The Cardiorespiratory cohort consists of Veterans admitted with a diagnosis of CHF, COPD and non-COVID-19 Pneumonia, and is a high-risk group for readmissions. As part of a larger National VA High Reliability Organization (HRO) Collaborative2, an interdisciplinary team was launched to achieve [...]