Background: Discharge to post-acute care settings (PACs), such as skilled nursing facilities (SNFs), requires significant, complex discharge planning which often needs to be started early during hospitalization to be complete by time of discharge. This study sought to identify and model factors which predict a given patient’s likelihood of requiring PAC after discharge, using routinely [...]

Background: Sub-optimal communication during care transitions contributes to poor patient outcomes. Patients who undergo interhospital transfer (IHT, the transfer of patients between hospitals) are at especially high risk given their level of illness severity. In examination of the IHT process at Brigham and Women’s Hospital (BWH), a 740-bed tertiary care referral hospital, we previously found [...]

Background: Discharge to post-acute care settings (PACs), such as skilled nursing facilities (SNFs), requires significant, complex discharge planning which often needs to be started early during hospitalization to be complete by time of discharge. This study sought to identify and model factors which predict a given patient’s likelihood of requiring PAC after discharge, using routinely [...]

Background: A fifth of older adults discharged from the hospital require readmission within 30 days. Readmissions impose an enormous burden on both patients and the healthcare system. Previous investigations have found that less than half of discharged patients are able to understand and execute the discharge plan and are likely to overestimate their comprehension of [...]

Background: Physicians and nurses often overestimate patients’ understanding of their illness, medications, treatments, and care plans. Fragmented discussions can lead to inconsistent conveyance of key information to patients and their caregivers. Multidisciplinary bedside rounds are an essential opportunity to facilitate patient-centered care. Our medical-surgical units did not have a standardized approach to ensuring consistent, clear [...]

Background: Frequently hospitalized patients represent a vulnerable population due to discontinuity between episodes of inpatient, outpatient, and specialty care. This discontinuity puts patients at risk for unnecessary over-treatment, dangerous under-treatment, medication errors, and loss of trust due to conflicting messages from healthcare providers. Providers face rising clinical volumes, decreasing familiarity between providers, and ever more [...]

Background: At academic centers the work of discharge planning has historically fallen on housestaff. The medical education community’s efforts to improve the trainee experience have led to an iterative process of duty hour reform and re-design. One effect has been “work compression” – each day a trainee is required to complete more tasks in less [...]

Background: Tests Pending at Discharge (TPAD) is a common patient safety concern at transitions of care due to provider discontinuity, suboptimal communication, and lack of ownership. A significant proportion of inpatients, up to 70%, are discharged with one or more TPAD. Recent studies show that 30-40% of resulted TPAD warrant a change in patient management. [...]

Background: The Improving Pediatric Patient-Centered Care Transitions (IMPACT) multi-site quality improvement collaborative aims to improve discharge transitions by use of a transition bundle, including use of a discharge checklist (DCL) to ensure completion of important transition tasks. These tasks included identification of a primary care provider, establishing follow up appointments, and ensuring access to medications, [...]

Background: Asthma is the leading chronic disease in children with prevalence approaching 10%. Barriers to follow up care, poor access to medication and lack of disease education pose a threat to patient safety and increase the risk for hospital re-utilization. The Improving Pediatric Patient Centered Care Transitions (IMPACT) collaborative designed and implemented a 4- element [...]