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: 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: 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: 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 […]

Background: The transfer of patients between hospitals, known as inter-hospital transfer (IHT), is associated with higher rates of mortality, longer lengths of stay, and higher hospitalization costs compared to admissions from the emergency department. Despite these poor patient outcomes, best practices to guide IHTs are lacking. To characterize the IHT process and identify key challenges […]

Background: Hospital discharge summaries are critical to transitions of care as they are oftentimes the only substantive form of communication that accompanies patients to their next care setting. The lack of interoperability in our healthcare IT ecosystem amplifies the need for discharge summaries to mitigate subsequent duplication of services and increased costs. These documents must […]

Background: At our institution, an interprofessional (IP) hospital team consisting of a hospitalist, pharmacist, and nurse practitioner, meets with IP teams from local skilled nursing facilities (SNFs) in a weekly teleconference to discuss patients recently discharged from the hospital to the SNFs. The purpose is to identify and reconcile gaps in care during patients’ transitions. […]