Background: Healthcare institutions have chronic bed shortages and a medically and socially complex patient population that makes optimal management of post-discharge care especially important. Effective and timely follow up post-hospitalization can improve clinical outcomes by delivering transitional care when patients are the most vulnerable. We developed a multimodal design that delivers education to patients and [...]

Background: Timeliness in transitional care improves clinical outcomes by delivering medical care at the most vulnerable post-hospitalization time. Primary care access to in-network and out-of-network patients’ post-hospitalization has been a challenge, especially to sicker patients with high risk of readmissions. Our institution Post-Discharge Clinic bridges this need by developing processes that will improve timely transitional [...]

Background: Our healthcare institution serves a large low-income, minority, and historically underserved population. The shortage of primary care physicians (PCPs) in our city and the high complexity of patients that are cared for by our organization is a challenge. Patients are in need of transitional care our institution and need help to connect to other [...]