Background: Many patients are discharged from the hospital to post-acute rehab in a skilled nursing facility (SNF). These care transitions can be error-prone, hampered by inadequate patient preparation for rehabilitation and insufficient communication between care providers. The readmission rate from SNF was 23.5% in 2006, costing Medicare $4.34 billion. Prior studies show 30% of these [...]

Case Presentation: We present a case of a 72 year-old independent woman on warfarin for recently-diagnosed pulmonary embolism, who was admitted to a local hospital for altered mental status. Upon presentation, a CT scan of the brain showed multiple areas of hemorrhage. The patient was transferred to our tertiary hospital for further management. An MRI [...]

Case Presentation: A 68 year-old male with hypertension and bipolar disorder presented with a 3-week history of memory deficits, weight loss, and increasing irritability. Exam revealed disorientation, dysarthria, and left sided weakness. MRI was suggestive of a right basal ganglia infarction. Patient was treated for a stroke and discharged. He was readmitted 30 days post-discharge [...]