Background: Medication reconciliation (MR) is a patient medication verification process performed by providers. Best practices and the intricacies of MR are poorly defined nationally, institutionally, and amongst individual providers. In graduate medical education, the skills of MR are implied and imperative in the Transitions of Care (TOC) Milestones 2.0. Prior institutional studies have indicated only […]

Background: Early discharge from the hospital improves hospital throughput as well as patient and staff satisfaction. At times, our emergency room tends to board many admitted patients for more than 24 hours, which further distresses our patients and staff. We noticed that the total number of patients leaving the hospital earlier in the day decreased […]

Background: Inter-hospital transfers are integral to a functioning health care network. Critical access, rural, and community hospitals established in sparsely populated territories are unable to support tertiary care infrastructure and rely on academic centers for consultation and transfer. Transfers comprise an estimated 3.5% of inpatient admissions (1), owing in part to increased procedural specialization concentrated […]

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: Our Hospital (Two Campuses A and B) is a part of Yale New Haven Health System (YNHHS). YNHHS is a nonprofit healthcare system in New Haven, Connecticut. Average length of stay (ALOS) for inpatients at Bridgeport Hospital remains longer than the national average. With the recent acquisition of another campus, inpatient volume at our […]

Background: Adverse events (AE) are common during care transitions (19-28%) in patients with multiple chronic conditions (MCC) and often lead to unanticipated healthcare resource utilization after discharge. While early indicators of these AEs include new and worsening symptoms, systematic monitoring of patient-reported symptoms is lacking. The 21st Century Cures Act mandates the healthcare industry to […]

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 […]

Background: Avoiding preventable readmissions is a major goal of health care systems nationwide1. The Cardiorespiratory cohort consists of Veterans admitted with a diagnosis of CHF, COPD and non-COVID-19 Pneumonia, and is a high-risk group for readmissions. As part of a larger National VA High Reliability Organization (HRO) Collaborative2, an interdisciplinary team was launched to achieve […]

Background: Close outpatient follow up is a key element of a safe and effective transition to home after hospitalization. For a wide variety of patients, including those with myocardial infarctions, heart failure, and other conditions, interventions that encourage follow up can reduce readmissions and in some cases mortality. However, competing demands by the clinical team […]

Background: Since the creation of Hospitalists in 1995, there has been much written about the importance of communication with primary care physicians (PCPs) as a routine staple of hospitalization. In practice, the inconsistent nature of hospitalist-PCP communication is well established. National surveys estimate the rates of communication to be between 20-40%. Amidst multiple barriers identified, […]