Background: Ten to twenty percent of U.S. hospitalizations are avoidable, driven by clinical uncertainty, social factors, or lack of access to ambulatory care [1-3]. These unnecessary admissions result in significant human and financial costs, including in-hospital errors, wasteful spending, and medical debt [4-7]. With hospital occupancy reaching critical levels, we designed and launched the Olive [...]

Background: Hospitalized patients and their families often face challenges in accessing and understanding developments in care plans, test results, and interdisciplinary decisions made during their stay. This knowledge gap causes anxiety, confusion, and missed opportunities for shared decision-making. Enhanced interdisciplinary communication and transparency with patients positively impacts patient satisfaction, readmission rates, patient safety and adherence [...]

Background: In a time when rural hospitals across the United States are closing for various reasons and local residents are left with limited access to healthcare, our academic medical center successfully built one of the few new rural facilities in the country and opened it in January 2023. The new hospital is a seventeen bed [...]

Background: Preventive care is a crucial but underutilized component of optimal population health management. Of eligible patients, 69.0% have received pneumococcal vaccine, 24.1% zoster vaccine, and 30.0% hepatitis B vaccine. Cancer screening rates are similarly low, with 12.5% screened for lung cancer and 71.6% for colorectal cancer. Gaps in preventive care are even larger in [...]

Background: Medication reconciliation (MR) is critical for patient safety during hospital admissions and transitions, though MR completion may be complicated by factors such as lack of familiarity with the electronic medical record (EHR) or missing information at admission. Over the past three years, our urban academic quaternary care hospital has led a successful MR improvement [...]

Background: Routine laboratory testing is a cornerstone of inpatient care. However, indiscriminate ordering can lead to resource waste, prolonged length of stay, and unnecessary costs. At our community teaching hospital in Queens, New York, we identified high rates of vitamin level testing—specifically vitamin B12, folate, and vitamin D25—which were often ordered without clinical indication. This [...]

Background: Pharmacist-led peri-discharge interventions reduce adverse drug events. However, evidence is lacking as to whether there is a business case to fund these non-billable interventions. To test whether such interventions could drive reductions in post-discharge health care utilization to help build a business case, we conducted a pragmatic randomized controlled trial (RCT). Methods: The PHARMacist [...]

Background: People experiencing homelessness (PEH) face barriers to accessing regular ambulatory care, which increases their risk of having poorly controlled chronic medical conditions and contributes to high acute care utilization. The role of field-based homeless healthcare teams in improving hypertension and diabetes control and reducing acute care utilization (e.g., emergency department [ED] visits, inpatient hospitalizations) [...]

Background: Hospitalizations related to opioid use disorder (OUD) are rising, creating opportunities to initiate medications for opioid use disorder (MOUD) and connect patients with outpatient resources.1,2 Despite evidence that MOUD reduces morbidity and mortality, most patients fail to receive evidence-based treatment during hospitalization.3-6 Addiction consultation services are becoming the standard of care to address this [...]

Background: Clinicians face an overwhelming volume of communication through various channels, including phone calls, text messages, emails, in-person interruptions, and secure messaging systems. This information overload is increasing[1] and poses significant challenges. Despite the availability of communication tools, failures in communication remain the leading cause of preventable medical errors [2]. Secure messaging systems, while essential, [...]