Background: Transition home after hospitalization carries significant risk of adverse patient events, readmissions and increased costs. Despite significant organizational efforts to improve care transitions, there continue to be challenges in implementing consistent interventions that impact key metrics of patient experience with the care transition and 30-day readmission rates. Purpose: Designing patient-centered systems which improve collaboration [...]

Background: Preventing readmissions of patients with chronic illness can improve healthcare outcomes and decrease costs. Previously reported Medicare claims data from 2003 to 2004 showed that 19.6% of Medicare beneficiaries discharged from the hospital were readmitted within 30 days at a cost of $17.4 billion. Our 232-bed community hospital has set a goal to reduce [...]