Background: Heart failure (HF) hospital readmissions are a leading cause of US 30-day hospital readmissions. Factors related to clinical complexity and unmet social needs are among the key drivers associated with HF negative clinical outcomes. Digital platforms have shown promise in improving HF outcomes but limitations like patient lack of familiarity with technology and unmet [...]

Background: Existing research describe older adults’ sub-optimal experiences of the hospital to skilled nursing facility (SNF) transition. However, these studies do not explore the causes of these poor experiences and neglect the complex clinical system in which these transitions occur. Therefore, the aims of this study were to identify the causes of patient experiences during [...]

Background: The transfer of patients between hospitals, i.e., interhospital transfer (IHT), introduces discontinuity of care including gaps in information transfer, which may worsen patient outcomes. In this study we aim to identify gaps in information exchange during IHT of medical patients from transferring hospitals of varying affiliation and electronic health record (EHR) integration to a [...]

Background: Inter-hospital transfer (IHT) care is complex and suffers from inefficiencies in information and task organization, which can contribute to high cognitive load for clinicians.[1-4] Cognitive overload can lead to medical errors and clinician stress.[5-8] Our study identifies specific areas of high cognitive load experienced by hospital medicine physicians and advanced practice providers (APPs) who [...]

Background: Older adults are commonly discharged to skilled nursing facilities (SNFs) after hospitalization. It is not known how patients anticipate SNF discharges and what they prioritize. The aims of this study are to explore what matters most to older adults during their hospital to SNF care transition. Methods: We conducted a grounded theory qualitative study. [...]

Background: Adverse events (AEs) occur in 19-28% of patients after discharge and can lead to unanticipated events, including emergency room visits and readmissions.(1,2) While early indicators include new and worsening symptoms (NWS), monitoring of patient-reported NWS is lacking. The 21st Century Cures Act mandates adoption of application programming interfaces (APIs), offering the potential to engage [...]

Background: Inter-hospital transfer (IHT), defined as the transfer of patients between acute care facilities, is a common practice. Despite assumptions that IHT is done to provide patients with necessary specialized care, the factors which drive patient transfer are highly variable in ways that are not fully explained by differences in patients or hospitals. As such, [...]