Background: As healthcare consolidation accelerates, healthcare systems must navigate logistical challenges in integration while continuing to provide high quality care to their patients. One area where this can be challenging is in a patient’s transition from one healthcare system to another; for example an inpatient transition to outpatient. This is a critical period as poor [...]

Background: There has been relatively little published regarding the transition from residency to faculty appointments. The learning curve during this transition is steep given the sudden increase in responsibility and is fraught with anxiety and trepidation. Given the high burnout and attrition rates within Hospital Medicine divisions, we sought to combat this through a structured [...]

Background: Increased hospital capacity causes significant strain on medical institutions. Patients who are clinically ready for discharge but “stuck” awaiting post-acute resources are thought to contribute to this capacity strain. Here, we aim to provide a clinically relevant measurement of the prevalence (proportion of patients) and weight (proportion of days) for patients who have spent [...]

Background: The strongest risk factor for readmission to the hospital and failure to successfully return to the community after hospital discharge is impaired physical function. Although published experience with wearable devices in post-acute care settings is scant, measurement of steps in other care settings has been shown to be feasible and directly linked with post-discharge [...]

Background: Emergency department (ED) crowding has been proven to worsen outcomes and increase mortality for patients presenting to the ED. Our innovative ED Surge program works collaboratively with our ED to transfer lower acuity patients to an on-site, same-day ambulatory setting after initial evaluation in the ED. We aim to characterize the impact of our [...]

Background: To support patients after hospital discharge, we developed and implemented a 30-day automated text-messaging intervention. The program was piloted in a single practice in Philadelphia, and was associated with a significant reduction in 30 day readmission and utilization of acute care resources. However, we wanted to understand the timing and nature of patient needs [...]

Background: One of the tools providers use in the discharge process to promote a safe transition of care is the written discharge instructions. Optimization of these instructions has been identified by physicians as a potential strategy to prevent readmissions. Our survey aimed to assess knowledge, attitudes, and self-reported practices of providers related to anticipatory guidance [...]

Background: Community acquired pneumonia (CAP) is one of the most common causes of hospitalization in the United States1 and a frequent source of antibiotic overuse.2 Two thirds of patients hospitalized for CAP receive excess antibiotic duration, primarily from excess therapy at discharge.3 Patients living in rural areas are known to have worse health outcomes than [...]

Background: The care management and discharge planning of psychiatric patients experiencing homelessness (PPEH) is an area of debate. Due to the lack of research on best practices and community resources available, there are currently insufficient actionable guidelines in place to properly assist PPEH in their psychiatric care post-discharge, leading to high rates of readmission. Though [...]

Background: Hospital admissions are stressful for adults with dementia and their caregivers. During care transitions from hospital to home, outcomes for adults with dementia depend, in part, on the caregiver’s health and well-being. We aimed to identify the resources and training needs of dementia caregivers during care transitions. Methods: We conducted semi-structured interviews with licensed [...]