Background: Discharge summaries (DS) play a large role in transition of care from the inpatient to outpatient setting. At academic centers DS are largely completed by house staff, though few residency programs and medical schools have dedicated education on DS and their role in transitions of care. At our institution discharge summary quality is variable, [...]

Background: U.S. healthcare costs are rising due to the increase in polypharmacy, which is a potential risk factor for hospital readmission.1 In a cohort study of 5,507 patients with ≥10 discharge medications, more than 25% of them were readmitted.1 At one of the largest public county hospitals in the U.S., readmission rates for patients with high-volume home [...]

Background: The HOSPITAL score is an internationally validated risk assessment to identify patients at risk of 30 day readmission for adults discharged from an inpatient medical department.1The HOSPITAL score is validated for all hospital admissions – acute and chronic. The purpose of this study was to assess the use of the HOSPITAL score to predict [...]

Background: Care transitions between hospitals, nursing homes, and home are a vulnerable time for patients.  Given the increasing elderly population and the shortage of primary care physicians with training in geriatrics or nursing home care, there is a growing need to identify organizational systems to optimize physician practice, enhance quality of care and increase educational [...]

Background: Hospitalized medical patients transitioning to new house staff at the end of an inpatient resident rotation are associated with an increased risk of mortality as compared with patients not exposed to such handoffs, yet no data exist on improvement strategies targeting this transition. Given the frequency with which residents rotate service, a transition in [...]

Background: Transitions from hospitals to the ambulatory setting are high risk periods for patients. Many interventions have been tried, with varying degrees of success, and often the problem has been with implementation rather than theoretical efficacy of the intervention.Methods: We developed, implemented, refined, and evaluated a multi-faceted, multi-disciplinary transitions intervention across two hospitals and 18 [...]

Background: Transitioning patient care between hospitals and skilled nursing facilities (SNFS) brings many challenges.  Patient and family anxiety, unfamiliarity and even misinformation about SNFs increase the opportunity for unsatisfactory outcomes and readmissions to the hospital..  Previous research has demonstrated frequent and potentially harmful medication discrepancies during hospital to nursing home transitions, and low frequency of [...]

Background: Transition of care between physicians remains a vulnerability in providing optimal patient care. The Clinical Learning Environment Review (CLER) program identifies Care Transitions as a core pathway for evaluation. Specifically, they assess a program’s educational process for handoff training and implementing standardized assessments to allow residents to move from direct to indirect faculty supervision. [...]

Background: Emergency department (ED) overcrowding is a commonly encountered challenge and is associated with adverse events and poor patient satisfaction.  One of the factors that can contribute to ED overcrowding is the boarding of admitted patients in the ED. Various methods have been implemented to improve this issue with limited success.     Purpose: A collaborative workgroup [...]

Background: Multiple studies have established that delays in discharge summary transmission were associated with higher rates of all-cause hospital readmissions.    It has been recently shown that delaying the completion of discharge summaries beyond 72 hours increased the risk of 30-day readmissions by 9%.  We had embarked on an initiative to improve the rate of discharge [...]