Background: The Palo Alto VA Hospital has an interdisciplinary Clinical Command Center (C3) that includes “Flow” nurse practitioners (NPs) who work closely with case management, social work and primary medical teams to identify and address barriers to care and assist in discharge planning and coordination. We have created a novel collaboration between a C3 Flow [...]

Background: 22% of the hospitals overall STAR rating is based on readmission reduction for the following disease specific groups: pneumonia, chronic obstructive pulmonary disease, acute myocardial infarction and congestive heart failure. Creating strategies surrounding prevention of readmissions that create workload balance leads to improved ability to manage these patients. The hospitalist medicine, emergency medicine, pulmonary, [...]