Background: Electronic prescribing (eRx) at discharge enhances safety and quality of care transitions. It results in improved medication adherence and a decreased chance of readmission. Stage 3 Meaningful Use goals include discharge eRx rates of greater than 25%. As of September 2017, our large academic medical center had a year-to-date discharge eRx rate of 18.3%, [...]

Background: Previous studies demonstrate patient readmissions to the Medical Intensive Care unit (MICU) from the ward are potentially associated with worse outcomes due to breakdowns in communication during ICU-ward transfer. Though previous work highlights the importance of shared mental models (whether clinicians have a mutual understanding) during handoffs, no studies examined the prevalence of a [...]

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: 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: Currently, Physical and Occupational Therapy (PT/OT) documentation dictates next site of care. PT/OT recommends how much therapy is needed upon discharge and where the therapist believes these services should be provided, which is often a Skilled Nursing Facility (SNF). This practice eliminates meaningful conversations between provider and patient regarding the patient’s wishes on next [...]

Background: Recurrent hospitalizations are responsible for considerable health care costs. This retrospective observational study was undertaken to determine whether timely communication of care (COC), such as direct phone call or voicemail notice, following a hospitalization is effective at increasing clinic follow-up rates and reducing readmissions within 30 days after discharge. Methods: We analyzed 237 patients [...]