Background: Many patients continue their post-acute care in settings such as skilled nursing facilities (SNFs). One in four hospitalized Medicare patients are discharged to SNFs. These patients are generally the elderly or require more care than patients discharged home, placing them at greater risk of clinical decline and rehospitalization. Moreover, 25% of patients discharged to […]

Background: Patients experiencing unsheltered homelessness are at extreme risk for worse outcomes, including increased mortality 10 times that of the general population and an average life expectancy of 53 (over 20 yrs less than general population). Transitions of care pose unique difficulties for this vulnerable population, with numerous barriers to ongoing care and resulting readmission […]

Background: Hospital readmission reduction has gained greater awareness since the passage of the Affordable Care Act and within it the Hospital Readmission Reduction Program (HRRP). Policy makers sought to improve quality of care by increasing reporting transparency and imposing financial penalties on facilities for excessive readmission rates. Baylor Scott & White Health (BSWH) remains committed to reducing hospital readmissions and in doing […]

Background: For patients at increased risk of hospitalization, reducing hospitalization is often a key objective and can have important effects on health care costs. The Comprehensive Care Physician (CCP) model was developed originally at the University of Chicago to reintegrate inpatient and outpatient care under the same physician for patients at high risk of hospitalization […]

Background: Failure to follow-up on lab tests and radiology results can lead to major patient safety concerns due to missed or delayed diagnoses and can be a cause for litigation for health care practitioners. With increasing patient loads, the volume of follow-up testing and clarifications to documentation needed for billing can be a significant burden […]

Background: Studies have demonstrated direct discharge to home with home care after hospitalization to be the optimal strategy for patients with social support. Even amongst sicker patients requiring intensive nursing and therapy services, evidence shows no difference in functional recovery when compared to those discharged to inpatient rehab. Furthermore, discharge location does not result in […]

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 […]

Background: Hospitalized patients with COVID-19 who improve clinically but have ongoing oxygen requirements are often discharged with home oxygen. There are important considerations for home monitoring, follow-up and education at the time of discharge for these patients who must manage new equipment at home. This project aimed to describe discharge planning for COVID-19 patients with […]

Background: Direct admissions (DA), wherein patients are non-emergently admitted to the hospital, bypassing the emergency room (ER), makeup 15% of non-elective adult hospitalizations (1). DAs can reduce ER volumes (2), but may lead to delays in initial evaluation of patients and inappropriate admissions (2,3). DAs carry risks involved with transitions of care and handoffs, yet […]

Background: Efficient discharge planning for hospital medicine patients requires alignment across multiple disciplines. Understanding how clinicians communicate information about discharge readiness can identify opportunities to improve discharge coordination and impact length of stay, hospital capacity, and patient satisfaction. The objective of this study was to outline the existing information gathering and communication pathways around discharge […]