Background: The Veterans Health Administration (VHA) is undergoing a national effort to improve access for its patients so that veterans can get the right care, in the right place, at the right time. National benchmarks suggest a time period of two weeks is adequate for non-acute specialty care follow-up, yet our hospital typically averages third [...]

Background: Hospital discharge describes the point at which inpatient hospital care ends, with ongoing care transferred to other providers. The coordination of such care typically involves multiple health care providers and social care contributors. The inherent complexity of coordinating a large number of players, often based in different settings and hospitals, leads to hospital discharge [...]

Background: Nurse-Physician communication around discharge ensures that essential information is conveyed to patients when they leave the hospital. Yet nurses and physicians report poor communication during this critical time. The aim of this study was to standardize nurse-physician discharge communication through a resident-led intervention of a “Discharge Time-Out” (DTO).  Methods: Previous surveys of nurses and [...]

Background: Failures in communication among healthcare personnel are known threats to patient safety. Communication is particularly vulnerable to error when patient care responsibility is transferred from one provider to another (i.e., handoff). In this study we implemented a web-based handoff tool and provider training, and evaluated the impact on preventable adverse events (AEs). Methods: We [...]

Background: Care transitions expose hospitalized patients to risks of discontinuity of care. Although various forms of care transitions have been widely studied, little is known about inter-hospital transfers (IHT, the transfer of patients between acute care hospitals). We used national Medicare data to examine the frequency of IHT and compare patient characteristics of transferred versus [...]

Background: Patients who are high utilizers of the health care system pose a significant burden to health care in the United States. These patients have higher rates of emergency department (ED) use, hospital readmission and cost compared to the general population, and tend to be medically, behaviorally and socially complex. Patients with high healthcare usage [...]

Background: Studies have shown that care transitions represent times of great risk, especially to vulnerable patients; medication reconciliation is a major component of ensuring safe care transitions. Yet, challenges exist to obtaining a best possible home medication list (BPHML) on a provider, patient, and institutional level. Academic hospitals have large pools of in-training providers. Safety [...]

Background: Against medical advice (AMA) discharges are often emotionally charged for healthcare providers. Complicated capacity assessments, confusion regarding legal and ethical obligations to patients, and limited resources may strain providers. This cross-sectional survey study explored provider perceptions, experiences, and self-assessed competence with AMA discharges at a county hospital with a high AMA rate. Methods: Surveys, [...]

Background: Pneumonia readmission rates are publicly reported and included as quality indicators in Medicare Value-Based Purchasing programs. The Yale New Haven Readmission Risk Score (YNHRRS) for Pneumonia is a tool that uses 25 variables including age, co-morbidities, and vital signs to predict readmission. Functional status and social support were not included in the YNHRRS, despite [...]

Background: Transitions from hospitals to the ambulatory setting are high risk periods for patients. The advent of the Patient-Centered Medical Home (PCMH) and Accountable Care Organizations (ACOs) provide an opportunity for true collaboration in which both inpatient and outpatient providers contribute to improving transitions in care. The goal of this study was to develop, implement, [...]