Background: Despite years of intense focus, inpatient and observation readmission rates remain high and largely unchanged. Little robust evidence exists to guide hospitals in the selection of interventions effective at reducing 30 day readmissions in real-world settings. Our local healthcare system incorporated the most recent recommendations for preventing readmissions into a comprehensive program called Transition [...]

Background: Higher rates of 30-day readmissions are associated with lower quality hospital care, and readmissions may put patients at risk for worse health outcomes including death. Historically, 20% of hospitalized Medicare beneficiaries were readmitted within 30 days, and many readmissions appeared avoidable. Accordingly, the Centers for Medicare and Medicaid Services (CMS) implemented the Hospital Readmissions [...]

Background: Hospital readmissions continue to remain prevalent despite their negative impact on patient outcomes and economic cost. One in five Medicare beneficiaries is expected to be readmitted within 30 days. As a result, strategies to reduce readmissions is a point of emphasis for all healthcare systems. Guidance regarding reducing readmissions differs and is not abundant. [...]

Background: Disruptions in normal life routines (such as sleep, function, nutrition, etc.) that commonly occur as part of routine hospital care may be traumatic for acutely ill patients and lead to a generalized condition of high risk after discharge that has been described as “post-hospitalization syndrome.” We created the ARCHES cohort study to measure these [...]

Background: Venous thromboembolism (VTE) in hospitalized medically ill patients is a leading preventable cause of morbidity and mortality in the United States. About half of VTE events occur following discontinuation of standard-duration in-hospital prophylaxis and hospital discharge. The APEX study evaluated Betrixaban for in-hospital to home VTE prophylaxis and is the first FDA approved anticoagulant [...]

Background: COPD exacerbations are among the leading causes of hospital readmissions. According to the COPD Foundation, in 2013, 22% patients admitted for COPD exacerbation required readmission within 30 days of discharge. This represents a significant burden in terms of morbidity for these patients and increased cost to the healthcare system. The COPD readmission rate during [...]

Background: Heart failure (HF) is a major public health concern that affects over 5 million adults in the US. HF is among the most common reasons for hospital admissions and presents a considerable cost burden to the medical system. Patients are stabilized and carefully monitored at the hospital but often go home without adequate follow-up [...]

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: 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 [...]

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 [...]