Background: Hospitalized patients often require post-acute care (PAC) after discharge ranging from long-term acute care hospitals (LTACH) to home health services. However, patients waiting for discharge to PAC are at risk for delayed discharges [1], which can increase in-hospital complications, increase costs, and decrease access to hospital care for other patients. [2, 3] Disposition prediction [...]

Background: Inadequate assessment and recognition of barriers to discharge at time of admission leads to delays in the discharge process and prolongation of hospital admissions. These delays are associated with multiple negative outcomes such as increased length of stay, decreased patient satisfaction, strain on hospital bed capacity, and higher readmission rates. Prior studies have shown [...]

Background: Existing research describe older adults’ sub-optimal experiences of the hospital to skilled nursing facility (SNF) transition. However, these studies do not explore the causes of these poor experiences and neglect the complex clinical system in which these transitions occur. Therefore, the aims of this study were to identify the causes of patient experiences during [...]

Background: The transfer of patients between hospitals, i.e., interhospital transfer (IHT), introduces discontinuity of care including gaps in information transfer, which may worsen patient outcomes. In this study we aim to identify gaps in information exchange during IHT of medical patients from transferring hospitals of varying affiliation and electronic health record (EHR) integration to a [...]

Background: Interdisciplinary rounds are an important part of care coordination on medical units and on teaching units they usually are resident-led. After restructuring interdisciplinary rounds in our institution, we began including attending physicians, with the goal to improve care coordination, discharge planning and team communication. Methods: The intervention was conducted on a 35-bed medical teaching [...]

Background: There are over 35 million discharges from inpatient hospitalizations annually in the US. During these transitions of care, patients are at risk for adverse events. It is crucial for patient safety to have accurate communication between the inpatient physician and the provider assuming care.The main conduit for this communication is the hospital discharge summary. [...]

Background: Black patients have distinct disadvantages that are associated with poor functional outcomes. Physical therapy (PT) is an invaluable tool for improving functional outcomes including hospital-associated disability and physical deconditioning. However, Black patients on trauma surgery services or with traumatic brain injury are less likely to be offered post-acute rehabilitation. Older White patients have higher [...]

Background: Inter-hospital transfer (IHT) care is complex and suffers from inefficiencies in information and task organization, which can contribute to high cognitive load for clinicians.[1-4] Cognitive overload can lead to medical errors and clinician stress.[5-8] Our study identifies specific areas of high cognitive load experienced by hospital medicine physicians and advanced practice providers (APPs) who [...]

Background: Patients’ confidence managing their health after discharge is essential to effective transitions of care. After Visit Summaries (AVSs) are a standard way of communicating discharge instructions. Past studies proposed solutions to improve discharge instructions and information retention, including simplified information pages, structured discharge letters, and graphic-based discharge information (DeSai et al., Lin et al., [...]

Background: Post-discharge phone calls to hospitalized patients have been associated with reduced 30-day readmissions.[1,2] But their impact during the COVID-19 pandemic is unknown. Further, whether the 30-day readmission metric is an accurate surrogate for care utilization remains a concern.[3-5] Since 2012, national all-cause readmissions have decreased while emergency department (ED) visits and observation status have [...]