Background: The 2001 Institute of Medicine Report Crossing the Quality Chasm cited a lack of care coordination as a contributing factor to the “chasm” between evidence-based and delivered care and suggests team-based models of care delivery. Hospitalists are tasked with increasing efficiency in inpatient care. LOS is designated as a measure of care coordination and [...]

Background: Transitions of care are known to be high-risk times in healthcare, largely due to communication errors between providers. Prior studies have shown a direct relationship between poor signout practices and adverse events. Verbal handoff tools, such as I-PASS, have been created in efforts to facilitate the signout process. An important aspect of the handoff [...]

Background: Patients recurrently admitted to the hospital frequently experience fragmentation of care and poor health outcomes, with discontinuity between hospital admissions resulting in unnecessary testing, ineffective or inconsistent treatment plans, patient/provider frustration, and inability to address the underlying medical and psychosocial issues that drive repeat hospitalization. Purpose: For patients with the highest inpatient utilization on [...]

Background: The high volume of handoffs between the Emergency Department (ED) team and the inpatient team on a daily basis makes this a ripe area for care improvement. Effective, safe and organized transitions facilitate high quality and efficient care, while a dysfunctional process negatively affects patients and practitioners and compounds overall hospital congestion and delays [...]

Background: Care Coordination Rounds (CCR) provide an opportunity for members of the multidisciplinary health care team to communicate as a group regarding the care and discharge planning of hospitalized patients. The use of CCR has been found to improve efficiency and patient experience, while reducing healthcare expenditures, inpatient length of stay, and unnecessary readmissions. The [...]

Background: High quality discharges improve patients’ health outcomes and experience and are a vital component of resident education. Our internal medicine residency program has had challenges in sustaining our efforts to improve discharge planning and in providing resident feedback on the process. Furthermore, despite access to “big data”, many residency programs struggle to find meaningful [...]

Background: Effective communication and care coordination between inpatient and outpatient teams are essential for safe care transitions. Currently there is infrequent communication between PCPs and Hospitalists around the time of discharge. Often, the PCPs are not aware of pending tests that need follow-up, and in the cases where they are aware of a pending test, [...]

Background: Health literacy (HL) is the measure of a person’s ability to obtain, process and understand basic health information and services to make appropriate health decisions.1 Previous studies note positive correlation between high HL and patient understanding of their condition.2 Patients with low HL have greater needs in transitional care domains, citing inadequate caregiver support [...]

Background: Both inappropriate hospital admissions and inappropriate discharges from the ED are associated with adverse patient outcomes. Little is known about the accuracy (sensitivity and specificity) of the hospital admission triage process. Purpose: We sought to understand the operating characteristics of our triage process to identify opportunities for improvement and project an optimal model. Description: [...]

Background: In 2014, the organization created the RRT, a multidisciplinary team that reviews care of frequently admitted patients, strategizes how to help these patients, and coordinates care to develop a treatment plan. Of the patients reviewed, the team delivered a 47% decrease in readmissions. Purpose: The RRT addresses the needs of complex, chronically ill patients [...]