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: 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 […]

Background: National guidelines recommend that pediatric health systems have written policies or guidelines addressing their approach to the pediatric to adult healthcare transition (HCT). It is unclear how inpatient care should be communicated in these policies, if at all. This is especially relevant as there are an increasing number of adults with childhood-onset conditions being […]

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: Studies, particularly the MARQUIS trial, have demonstrated the value of pharmacist-led medicine reconciliation. At our institution, we partnered with the College of Pharmacy to implement, revise, and grow a novel hospitalist-led transitions of care pharmacy student rotation. Pharmacy students work directly with attending hospitalists to address admission medication reconciliation errors and collaborate in the […]

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. […]