Background: Successful discharge practices and avoidance of readmission requires attention to social needs and care coordination with outpatient care providers. While national programs have attempted to identify interventions within the care continuum to prevent readmission, these programs rarely involve inpatient hospitalists. While robust requirements for certain care transitions processes such as medication reconciliation and discharge [...]

Background: Timely, effective follow-up after hospital discharge can improve the efficiency and outcomes of care by increasing hospital throughput and decreasing readmissions and other adverse events after discharge. The University of Chicago Medical Center (UCMC) has chronic bed shortages and a medically and socially complex patient population that makes optimal management of post-discharge care especially [...]