Background: Day-to-night inpatient handoff is a high-risk moment, with potential for miscommunication. A novel handoff program recently reduced medical errors and preventable adverse events. Historically, handoffs performed by Internal Medicine residents at our institution were not standardized and there was little workplace-based performance feedback. We evaluated the impact of a novel standardized handoff tool and [...]

Background: Improving patients’ readiness for discharge is an important aspect of care transitions. Eliciting barriers to discharge from patients and providing daily feedback to their physicians may provide an approach to identifying and addressing problems early in patient stays. Methods: We enrolled a random sample of patients admitted to the Medicine Service at a tertiary [...]

Background: The role of discharge instructions in post-discharge recovery remains unexplored.  We examined the role of discharge instructions in post-discharge care for patients undergoing colorectal surgery and report themes related to patient perceptions of discharge instructions and post-discharge experience.  Methods: Semi-structured interviews were conducted as part of a formative evaluation of a Project Re-Engineered Discharge [...]

Background: Patients who are at risk for readmissions and emergency department visits following hospital discharge frequently have multiple medical comorbidities and a history of multiple prior hospitalizations. Over the past five years, reducing hospital readmissions has increasingly become a priority for hospitals, and effective interventions to reduce readmissions have included multiple components and multiple disciplines. [...]

Background: In 2012, nearly one-third of older adults (>65 years) with Medicare discharged to home after hospitalization were referred for home health care (HHC) services. Care coordination between healthcare settings is frequently inadequate. We sought to describe care coordination challenges and potential solutions from the perspective of HHC nurses. Methods: We conducted a qualitative descriptive [...]

Background: Patients recurrently admitted to the hospital account for a disproportionate percentage of hospital costs and frequently experience fragmentation of care and poor health outcomes. On our hospitalist service at a large academic medical center, patients admitted five or more times per year make up less than 1% of patients but approximately 5% of admissions. [...]

Background: The period following hospital discharge is a vulnerable time for patients when increased self-care requirements are common. Low levels of health literacy and social support are thought to contribute to poor post-discharge outcomes. However, little research has specifically examined the role of health literacy alone or in combination with social support in predicting readmission [...]

Background: The current process of transitioning to a skilled nursing facility (SNF) is non-transparent and inefficient. For patients and caregivers, the process is stressful and confusing. For the providers and the hospital, it could result in lower patient satisfaction and increase patient length of stay. For SNF administrators, it often causes a mismatch of patient [...]

Background: One in five hospitalized patients has diabetes. Despite guideline recommendations for regular outpatient vision care, studies show gaps in outpatient vision assessments. The hospital setting may be an opportunity to identify patients with diabetes who may need further vision care after discharge, but few studies have evaluated vision status among inpatients with diabetes. Our [...]

Background: Effective patient handoffs during care transitions are crucial in the skilled nursing home setting where physician providers may not round on a daily basis, and the healthcare facility staff has shift changes on a daily basis. Currently, many critical communications regarding patients are shared via private phone calls, text messages, emails and log books. [...]