Background: Hospitalized older adults are increasingly referred to skilled nursing facilities (SNFs) for post-acute care following hospitalization. However, whether hospitalized older adults are enabled to make high-quality decisions about different post-acute care options is unclear. This is important because a high-quality decision aligned with patient values and expectations may lead to a better match of [...]

Background: Communication has been cited as the most common root cause in sentinel events, with failed patient care handoffs contributing to an estimated 80% of serious preventable adverse events. Handoffs to sub-acute care such as nursing homes are at particularly high risk for communication breakdown given high patient complexity and comorbidity. Our healthcare system includes [...]

Background: With advances in medical care, there is a growing population with childhood-onset chronic health conditions reaching adulthood. A 2011 consensus statement by the AAP, AAFP and ACP identified an algorithm for transition from pediatric to adult care, but change in practice has been slow. The purpose of this study was to better understand the [...]

Background: Patients discharged against medical advice (AMA) have disproportionately high healthcare costs and increased morbidity, mortality, and hospital readmissions. While patient risk factors for discharge AMA are known, there is little data regarding providers’ practice patterns during AMA discharge, including provision of follow-up appointments. Similarly, the frequency of a documented discussion of the risks and [...]

Background: Patients admitted to inpatient hospital services are increasingly cared for by hospitalists rather than their primary care providers. When transitioning from hospital-based to ambulatory care, suboptimal information transfer can lead to serious adverse events and readmissions; therefore, demands for timely preparation of high-quality discharge summaries are increasing. Confronted with these demands, most hospitalists are [...]

Background: Hospital admissions are the majority contributor to the cost in caring for diabetes, accounting for about 40% of the costs. As most hospital reimbursements are based upon diagnosis-related groups, hospitals have strong financial incentives for quicker discharges to control length of stay and costs. This can limit the time available to develop a comprehensive [...]

Background: Patients diagnosed in-hospital with acute venous thromboembolism (VTE) are at high risk for post-discharge complications and readmission similar to patients with chronic conditions. Patient navigation reduces post-discharge complications and readmissions in patients with chronic diseases, however its role in acute conditions is less clear. Similarly, the use of mobile technology to improve patient engagement [...]

Background: National readmission rates for all-cause hospitalizations are as high as 14 readmits per 100 index admissions and have been relatively unchanged for at least the last 5 years (Fingar K, et al. Agency for Health Care Policy and Research, 2015). Since January of 2013, the Centers for Medicare & Medicaid Services has adopted a [...]

Background: Financial readmission penalties hold hospitals responsible for 30-day readmissions regardless of whether the patient was readmitted to another hospital.  Emerging evidence suggests patients readmitted to non-index hospitals may experience higher mortality rates.  Hospitals with large proportions of patients readmitted elsewhere may need to alter their approach to these readmissions, but how often patients are [...]

Background: Transfers to academic tertiary care centers often involve complicated patients requiring subspecialty consultation and coordination of care.   Therefore appropriate handoff and communication from sending to receiving institution is needed to streamline care and minimize redundancies. At our institution, we received approximately 1200 transfer requests annually.  Process improvement carries the potential to impact many patients [...]