Background: Patients, particularly the elderly and those who have chronic illnesses, often experience adverse events when transitioning from the hospital to home. An estimated 20% of all discharged patients suffer a preventable adverse event (e.g., reaction to medication) within three weeks of discharge and 20% of Medicare patients are readmitted to the hospital within 30 [...]

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: 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 [...]